
Class 

Book V/ r 



COPYRIGHT DEPOSJF. 



r 



THE HOME MEDICAL ADVISER 



THE HOME 
MEDICAL ADVISER 

A POPULAR WORK ON 

THE TREATMENT OF DISEASE 

INCLUDING 

FIRST AID IN INJURIES AND POISONING; THE MORE COM- 
MON DISEASES IN MEDICINE, SURGERY AND THE VARIOUS 
SPECIALTIES— AS THE EYE, EAR, NOSE, AND THROAT, SKIN, 
AND DISORDERS OF WOMEN AND CHILDREN. ALSO DE- 
SCRIBING THE CARE AND FEEDING OF CHILDREN, HOUSE- 
HOLD MEDICINES, SEXUAL HYGIENE, ETC. 

BY 

KENELM WINSLOW, M.D., B.A.S. (Harvard) 

FORMERLY ASSISTANT PROFESSOR COMPARATIVE THERAPEUTICS, HARVARD UNIVERSITY; ATTENDING PHYSICIAN 

TO SEATTLE CITY HOSPITAL AND KING COUNTY HOSPITAL, WASHINGTON; FELLOW MASSACHUSETTS 

MEDICAL SOCIETY; LATE VICE-PRESIDENT AMERICAN ASSOCIATION FOR THE STUDY AND 

PREVENTION OF INFANT MORTALITY; AUTHOR OF "THE PREVENTION OF 

DISEASE," "THE PRODUCTION AND HANDLING OF CLEAN MILK," 

ETC., ETC. 




WITH ILLUSTRATION 



NEW YORK AND LONDON 
D. APPLETON AND COMPANY 

1917 






Copyright, 1917, by 
D. APPLETON AND COMPANY 



JAN -9 19(7 



Printed in the United States of America 



©CI. A 4 3 358 5 



TO 
M. O. W. 

THE INSPIRATION OF 
THE FIVE YEARS OF 
LABOR ON THIS BOOK 



PREFACE 

In writing a popular medical treatise the author is thoroughly 
aware that he is entering a well-tilled field. 

A similar work by him, however, published many years ago, met 
with such unusual success in the demand for over one hundred thou- 
sand copies that with riper experience and greater knowledge it may 
not be unreasonable to hope for a favorable reception of this new 
volume treating of the more recent progress in scientific medicine. 

Three essentials have seemed paramount in the preparation of 
such a work: truth, simplicity and clarity. 

An attempt has therefore been made to present the subject in a 
clear, terse, simple style, while strictly adhering to scientific accuracy 
and the canons of medical ethics. 

There has been no desire to usurp the functions of the physician ; 
on the contrary, the wish has been to aid his usefulness by giving the 
public a more intelligent understanding of scientific medicine, thus 
abolishing the mystery which has enshrouded the practitioner in the 
past. 

Emphasis has been laid upon the prevention of disease — the chief 
aim of modern medicine. 

Finally it may be affirmed that, in emergencies and at various 
times and places, the possession of a sound, practical reference book, 
or Medical Adviser, will prove not only of greatest service but even 
of life-saving value. 

Kenelm Winslow 
Seattle, Washington. 



CONTENTS 



PART I 

CHAPTER I 
WOUNDS— SPRAINS— BRUISES 

PAGE 

First aid in wounds. Arrest of bleeding- in wounds of arteries and 
veins in special parts of the body. Bleeding after the extraction 
of a tooth. Bleeding 1 from varicose veins in the legs. Bleeding 
from the lungs. Vomiting of blood. Bleeding from the bowels. 
Immediate care of fresh wounds. Cleansing, dressing and cover- 
ing the wound. Stitching the wound. Incised wound. Lacer- 
ated and contused wounds. Punctured wounds. Scalp wounds. 
Bullet wounds. Blank cartridge and toy pistol wounds. Rifle 
bullet wounds. After-treatment of wounds. Lockjaw. Sprain 
of the back. Sprain of the hip. Sprain of the knee. Sprain 
of the ankle. Sprain of the fingers or thumb. Sprain of the 
wrist. Sprain of the elbow. Sprain of the shoulder. Bruises. 
Abrasions. Small cuts . . 1-35 

CHAPTER II 

DROWNING— ELECTRIC SHOCK— POISONING BY GASES 

Drowning. Restoring the apparently drowned. Rescuing a drowning 

person by swimming. Electric shock. Poisoning by gases . 36-43 

CHAPTER III 

UNCONSCIOUSNESS AND CONVULSIONS 

General treatment. Sunstroke. Heat prostration. Heat stroke. 
Fainting. Intoxication. Head injuries. Concussion. Com- 
pression of the brain. Fracture of the skull. Apoplexy. Kid- 
ney disease. Epilepsy. Hysteria. Diabetes. Surgical shock. 
Poisoning by opium, carbolic acid and strychnin. Convulsions 
in children. Convulsions in adults . . . . ■•"."•• 44-57 

ix 



x CONTENTS 

CHAPTER IV 
FRACTURES OR BROKEN BONES 

PAGE 

Special fractures. Broken rib. Collar bone fracture. Lower jaw 
fracture. Fracture of the nose. Shoulder-blade fracture. Arm 
fracture. Fracture of the wrist. Fracture of bone of hand or 
fing-er. Broken finger. Hip fracture. Thigh bone fracture. 
Knee-pan fracture. Fracture of leg bones between knee and 
ankle. Ankle joint fracture. Fracture of the bones of the foot. 
Compound or open fracture of the leg 58-81 



CHAPTER V 

DISLOCATIONS 

Treatment. Dislocation of the jaw. Dislocation of the shoulder. Dis- 
location of the elbow. Dislocation of the hip. Dislocation of 
the thumb and fingers . . 82-91 



CHAPTER VI 

SURGICAL DRESSINGS AND BANDAGES OF VARIOUS KINDS 
FOR DIFFERENT PARTS OF THE BODY 

Surgical dressings. ' Bandages of the limbs. T-bandage. Spica, or 
figure-of-eight bandage. Spica of the ankle and foot. Triangu- 
lar and cravat bandage of the thigh. Triangular bandage of the 
foot. Triangular bandage of the head. Triangular bandage of 
the breast. Cravat bandage of the jaw. Cravat bandage of the 
eye. Cravat bandage of the shoulder. Transportation of the 
injured 92-103 



CHAPTER VII 

GROWTHS AND SWELLINGS 

Tumors. Malignant tumors. Cancer. Cancer of the breast. Cancer 
of the womb. Cancer of the lip. Sarcoma. Benign tumors. 
Goiter. Exophthalmic goiter. Myxedema. Rupture. Varicose 
veins. Variocele. Piles 104-123 






CONTENTS xi 

CHAPTER VIII 
MISCELLANEOUS COMMON SURGICAL DISORDERS 

PAGE 

Bunion. Housemaid's knee. Callus. Corns. Ingrowing toe nail. 
Run -around (whitlow or felon). Weeping sinew or ganglion. 
Foreign bodies in the eye, ear and nose. Swallowing foreign 
bodies. Boils. Carbuncles. Snake bites. Rabies (hydropho- 
bia) 124-143 

CHAPTER IX 

SKIN DISEASES— BITES AND STINGS OF INSECTS 

Skin diseases. Itching. Chafing and chapping. Hives. Nettle rash. 
Pimples. Blackheads. Cold sore — fever blister. Prickly heat. 
Ringworm of the body. Ringworm of the scalp. Freckles, tan 
and other discolorations of the skin. Ivy poison. Warts. Bald- 
ness. The itch. Callus and cracks of the skin. Eczema. Ery- 
sipelas. Bites and stings of insects. Mosquitoes, bees, wasps 
and hornets. Wood ticks. Lice. Fleas. Bedbugs. Jiggers or 
sand fleas. Flies. Scorpions. Centipedes. Spiders. . . 144-173 

CHAPTER X 

POISONS AND ANTIDOTES— FOOD POISONING 

Poisons and antidotes. General rules. List of poisons and antidotes. 
Food poisoning, including meat, fish, cheese, ice cream, potato 
and canned food poisoning. Tapeworm. Roundworms. Pin- 
worms (seatworms — threadworms). Trichiniasis. Hookworm 
disease 174-193 

CHAPTER XI 

MENSTRUATION AND ITS DISORDERS— DISEASES OF WOMEN- 
CHANGE OF LIFE 

Menstruation. Care of normal menstruation. Painful menstruation. 
Absence of menstruation (amenorrhea). Beginning menstrua- 
tion suddenly arrested. Scanty or delayed menstruation. Flow- 
ing, bleeding or hemorrhage from the womb. Emergency treat- 
ment of flowing. The whites (leukorrhea). Signs of pregnancy. 
Miscarriages. Death of child in the womb. Change of life 
(menopause) 194-209 



xii CONTENTS 

CHAPTER XII 
PREGNANCY 

PAGE 

Hygiene of pregnancy. Treatment of ills accompanying pregnancy. 
List of articles required for childbirth. Care of the mother 
during childbirth in the absence of a doctor. Care of the mother 
after childbirth 210-231 

CHAPTER XIII 

CARE OF THE BABY AFTER BIRTH 

Immediate care after birth. Bathing. The skin. Clothing. Tem- 
perature. Ventilation and fresh air. Weight. Walking and 
talking. Bowel discharges. Teething. Nursing at the breast. 
Bad habits. Masturbation. Sleeplessness. Sucking. Bed- 
wetting. Feeding of infants from the bottle. Approximate 
composition of cow's milk. Composition of women's milk. 
Feeding during the first week. Feeding during the second week. 
Feeding during the first seven months. Food in addition to milk 
allowed the first year. Utensils necessary for preparing infants' 
food. Details of preparation of milk and care of utensils . 232-252 

CHAPTER XIV 

FOOD FOR INFANTS AND THE SICK 

Barley and oatmeal water. Barley gruel. Beef juice. Orange juice. 
Water. Egg-white, coddled egg. Veal, chicken, beef or mutton 
broth. Albumen or egg water. Whey. Scraped beef. Beef 
tea. Peptonized milk. Junket or milk curd. Milk porridge. 
Soft custard. Eggnog. Clam broth. Oyster broth. Condensed 
milk. Patent or proprietary foods for babies. Diet for children 
from first to sixth year . 253-264 

PART II 

CHAPTER I 

PERSONAL HYGIENE 

Baths. Cold baths. Outdoor bathing. Tepid or lukewarm bath. 
Warm bath. Hot bath. Turkish bath. The complexion. The 
hair. Finger and toe nails. Clothing. Footgear . . . 265-273 



CONTENTS xiii 

CHAPTER II 
PERSONAL HYGIENE (Continued) 

PAGE 

Hygiene of the digestion. Care of the teeth. Riggs' disease. Con- 
stituents of food, including meats, fish, shellfish, eggs, milk, 
vegetables, cereals, bread, fruits, salts and water, and their val- 
ues as articles of diet. The function of cooking. Tea and coffee. 
Alcohol. Tobacco 274-301 

CHAPTER III 

PERSONAL HYGIENE (Continued) 

Exercise in general. Effect of exercise on the body as a whole. Ex- 
cessive exercise. Exercise for different ages . . . . 302-308 

CHAPTER IV 

PERSONAL HYGIENE (Continued) 

Heredity. General considerations. Environment versus heredity . 309-318 

CHAPTER V 

HOW TO TAKE TEMPERATURE, PULSE, AND RESPIRATION- 
APPEARANCE OF THE TONGUE—HOW TO GIVE SUBCU- 
TANEOUS INJECTION AND PASS A CATHETER. 

Temperature. Pulse. Respiration or breathing. Appearance of the 

tongue. Hypodermic syringe. Use of the catheter . . 319-326 

CHAPTER VI 

DISEASES OF CHILDREN 

Inflammation of the breast of the newborn. Small opening in the fore- 
skin for passage of urine (phimosis). Bleeding of the cord and 
soreness of the navel in the newborn. Prolapse of the bowel. 
Wasting. Soreness, swelling and pain in the legs — growing 
pains. Fever. Enlarged glands of the neck and other parts — 
tuberculous glands— scrofula. Rickets. Spasm of the larynx — 
"holding the breath." Chorea (St. Vitus's dance). Pott's dis- 
ease of the spine. Lateral spinal curvature. Hip disease. 
Bow-legs. Knock-knees. Weak and flat feet . . . 327-354 



xiv CONTENTS 

CHAPTER VII 
INFECTIOUS DISEASES 

PAGE 

The infectious eruptive fevers. Scarlet fever. Measles. German 

measles. Smallpox. Chickenpox 355-380 

CHAPTER VIII 

INFECTIOUS DISEASES (Continued) 

Mumps. Whooping-cough. Typhoid fever. Epidemic cerebrospinal 

meningitis. Information regarding prevention of meningitis . 381-402 

CHAPTER IX 

INFECTIOUS DISEASES (Continued) 

Diseases due solely to the bites of mosquitoes. Malaria. Chronic 
malaria. Pernicious malaria. Black water fever. Yellow 
fever 403-420 

CHAPTER X 

THE NOSE, MOUTH AND THROAT 

Nosebleed. Cold in the head. Foreign bodies in the nose. Foreign 
bodies in the throat. Sore mouth (stomatitis). Canker. Smok- 
er's tongue (leukoplakia). Foul breath. Mild sore throat 
(acute pharyngitis). Ulcerated tooth (alveolar abscess). 
Toothache from decay and cavity. Mouth breathing. Adenoids. 
Enlarged tonsils. Nasal obstructions. Acute (follicular) ton- 
sillitis. Quinsy or abscess of the tonsil. Diphtheria. Mem- 
branous croup. Hoarseness (acute laryngitis). Croup . . 421-457 

CHAPTER XI 

DISEASES OF THE AIR PASSAGES 

Cough. Bronchitis. Pneumonia, Consumption. Asthma. Hay 

fever. Influenza (la grippe) 458-482 



CONTENTS 



CHAPTER XII 



XV 



DISEASES OF THE HEART, THE BLOOD AND THE BLOOD 

VESSELS 

PAGE 

Diseases of the heart. Heart disease. Palpitation of the heart. Dis- 
eases of the blood and blood vessels. Deficiency in quantity or 
quality of the blood (anemia). Degenerative changes of age. 
Hardening of the arteries (arteriosclerosis) .... 483-494 



PART III 

CHAPTER I 

VOMITING AND JAUNDICE 

Vomiting. Sea sickness and car sickness. Vomiting of blood. Jaun- 
dice. Biliousness 495-504 

CHAPTER II 

CHRONIC STOMACH TROUBLES 

Gall-bladder disease. Chronic ulcer of the stomach and the first part 
of the bowel (duodenum). Cancer of the stomach. Stomach 
trouble from chronic appendicitis. Functional indigestion. # 
Faulty development and posture (enteroptosis). Atony of the 
stomach. Nervous indigestion 505-529 

CHAPTER III 

DISEASES CAUSING SEVERE ABDOMINAL PAIN 

General treatment of intense abdominal pain. Acute appendicitis. 
Renal colic. Mucous colic. Sudden obstruction of the bowels. 
Inflammation of the bowels (peritonitis) .... 530-545 

CHAPTER IV 

DIARRHEAL DISEASES— CONSTIPATION 

Diseases of adults. Acute and chronic diarrhea. Acute and chronic 
dysentery. Cholera morbus. True cholera (Asiatic cholera). 
Constipation. Diet for constipation. Diseases of infants and 



xvi CONTENTS 

PAGE 

children. Simple diarrhea or acute intestinal indigestion. Sum- 
mer diarrhea of infants (ileocolitis). Cholera infantum (acute 
milk infection). Constipation in infants and children . . 546-574 

CHAPTER V 

DISORDERS OF NUTRITION 

Diabetes. Test diet for diabetics. Additional articles of diet. Quan- 
tities allowed in mild cases. Forbidden foods. Food allowed 
by permission. Diet in severe cases. Obesity. Table of height 
and average weight in varying ages. Table showing average 
weight of insured women. Diets advised in the treatment of 
obesity. Milk cure diet. Articles to be avoided in obesity. 
Beriberi. Scurvy. Infantile scurvy. Pellagra. Gout . . 575-602 

CHAPTER VI 

RHEUMATISM AND ALLIED DISEASES 

Inflammatory rheumatism — acute rheumatism (rheumatic fever). Mus- 
cular rheumatism (myalgia). Lumbago. Stiff neck. Rheuma- 
tism of the chest. Chronic deforming joint diseases . . 603-612 

CHAPTER VII 

NERVOUS DISEASES 

Nervous exhaustion — nervous debility (neurasthenia). Hysteria. 
Sleeplessness (insomnia). Headache. Sick headache (mi- 
graine) 613-631 

CHAPTER VIII 

NERVOUS DISEASES (Continued) 

Hiccough. Facial paralysis. Neuralgia. Facial neuralgia. Sciatica. 
Convulsions in children. Epilepsy. Delirium tremens. Chronic 
alcoholism or steady drinking 632-649 

CHAPTER IX 

ACUTE AND CHRONIC BRIGHT'S DISEASE OF THE KIDNEYS 

Bright's disease of the kidneys. Acute Blight's disease (acute inflam- 
mation of the kidneys). Chronic Bright's disease . . . 650-654 



CONTENTS xvii 

CHAPTER X 
GENITO-URINARY DISEASES 

PAGE 

Gonorrhea in men. Gonorrhea in women. Syphilis (the pox — lues). 
Prevention of gonorrhea and syphilis. Inflammation of the 
bladder (cystitis). Retention, stoppage, or suppression of urine. 
Involuntary passage of urine — bed-wetting in children . . 655-675 

CHAPTER XI 

SEXUAL HYGIENE 

General considerations. Prevention of unhygienic conditions . . 676-684 

CHAPTER XII 

THE EYE AND EAR 

Diseases of the eye: Cinders and other foreign bodies in the eye. 
Black eye. Inflammation of the edge of the eyelids. Stye. 
Twitching of the eyelids. Wounds and burns about the eyes. 
Congestion of the eyelids. Catarrhal inflammation of the eyes 
(conjunctivitis). Pink eye. Eye strain. Far- and near-sight. 
Astigmatism. Weakness of the eye muscles. Diseases of the 
ear: Deafness. Foreign bodies in the ear. Earache. Mastoid 
inflammation 685-713 

CHAPTER XIII 

BURNS AND FROSTBITE 

Burns and scalds. Frostbite. Chilblains and mild frostbite. Treat- 
ment of general effects of cold . .... 714-720 

CHAPTER XIV 

THE MEDICINE CHEST 

Necessary drugs and doses of drugs. Doses for adults. Doses for 
babies one year old. Table showing doses for children at speci- 
fied ages 721-726 

First Aid Surgical Outfit 727-728 

Index 731 



LIST OF ILLUSTRATIONS 




FIGURE 

1. Method of strapping a knee 

2. Good method of strapping a sprained ankle with adhesive plaster 

3. Adhesive plaster strapping for sprain of the thumb 

4. Expelling water from the stomach and lungs 

5. Sylvester's method of artificial respiration (inspiration) 

6. Sylvester's method of artificial respiration (expiration) 

7. Artificial respiration — Howard's method 

8. Strapping with adhesive plaster for broken rib 

9. Sling for collar bone fracture 

10. Sling for collar bone fracture 

11. Treatment of fracture of the collar bone 

12. Four- tailed bandage for fracture of the lower jaw 

13. Treatment of fracture of the jaw by means of a four-tailed bandage 

14. Fracture of the nose dressed with two small bandages and adhesive 

strips 

15. Treatment of fracture of bone of arm 

16. Treatment of fracture of bone of arm 

17. Treatment of fracture in forearm . 

18. Fracture of the wrist 

19. Break of bone in back of hand corresponding to right middle finger 

20. Fracture of the finger ......... 

21. Splints used in transportation in case of fracture of shaft of thigh 

22. First-aid treatment of fracture of both bones .... 

23. Umbrella used as temporary splint in fracture of the leg . 

24. Dislocation backward of both bones of forearm .... 

25. Spiral reverse bandage of thigh, showing the introduction of the first 

reverse . . 

26. Spiral reverse bandage of thigh completed . 

27. T-bandage 

28. Figure-of-eight or spica bandage of the thigh 

29. Figure-of-eight or spica bandage of the shoulder 

30. Figure-of-eight bandage of the ankle and foot 

31. Figure-of-eight bandage of the hand 

32. Gauntlet bandage, showing the completion of the bandage of one 

finger ........ 

33. Figure-of-eight bandage of the elbow . 

34. Spiral reverse bandage of the leg . 

35. Triangular bandage folded once and twice . 

36. Triangular and cravat bandage of the thigh 

37. Triangular bandage of the foot 

38. Triangular bandage of the head 



PAGE 

27 
29 
30 
36 
37 
38 
42 
60 
61 
61 
62 
64 
64 

65 
67 
67 
69 
70 
71 
72 
75 
78 
78 



94 
94 
95 
95 
96 
97 
98 

98 
99 
99 
100 
100 
100 
100 



xx LIST OF ILLUSTRATIONS 

I Hi IKK PAGE 

oil. Triangular bandage of the head 101 

40. Triangular bandage of the breast 101 

41. Cravat bandage of the jaw 101 

42. Cravat bandage of the eye 102 

43. Cravat bandage of the shoulder 102 

44. Blanket stretcher 103 

45. Sites of rupture 114 

46. (A) Proper shape of sole of shoe; (B) Flat sole in profile of a shoe . 272 

47. Lateral curvature of the spine 346 

4S. Bow-legs 349 

49. Knock-knees . 350 

50. Weak feet seen in front 351 

51. Weak feet seen behind . 351 

52. (A) Print of normal foot; (B) Print of flat foot . . . • . 352 

53. Modified Thomas heel . . ■ .353 

54. (A) Anopheles mosquito; (B) Culex or common mosquito . ' . . 404 

55. Site of frontal sinus; site of antra of Highmore 426 

56. Quinsy or abscess of the tonsil 444 

57. Position of gall-bladder and appendix t . . 501 

58. Enteroptosis showing head forward, shoulder blades and lower part of 

belly prominent ........... 518 

59. Faulty posture, favoring enteroptosis . . . . . . . 519 

60. Faulty posture, favoring enteroptosis 520 

61. Faulty posture, favoring enteroptosis 521 

62. Enteroptotic build 523 

63. Normal broad chest — wide angle between rib margins, giving wide 

upper abdomen 524 

64. Belt for enteroptosis 524 

65. Usual point of lodgment of foreign body on inner surface of upper lid 685 

66. Farsighted eye focusing parallel rays of light behind the retina . 693 

67. Focusing of light rays in a normal eye 693 

68. Farsighted eye showing the focusing of rays from near and far objects 

behind the retina 694 

69. The lens during accommodation and at rest 694 

70. Nearsighted or myopic eye focusing parallel rays from a distant object 697 

71. Simple hyperopia astigmatism 698 

72. Simple hyperopia astigmatism corrected by a convex cylindrical glass . 698 

73. Outside of the eyeball 700 



THE HOME MEDICAL 
ADVISER 

PART I 

CHAPTER I 
WOUNDS— SPRAINS— BEUISES 

Arrest of bleeding in wounds of arteries and veins and in special parts of 
the body. Arrest of bleeding after extraction of teeth, in ruptured 
varicose veins, from lungs, stomach, bowels, and piles. Immediate care 
of fresh wounds, stitching wounds, care of lacerated, contused, punc- 
tured, and bullet wounds. After-treatment of wounds. Lockjaw. 
Sprains of the back, hip, knee, ankle, fingers. Bruises, abrasions, and 
cuts. 

FIRST AID IN WOUNDS 

A wound is a break or cut in any of the soft tissues of the body 
caused by external violence. In the treatment of wounds the matter 
of supreme importance is surgical cleanliness. This means that 
nothing chall touch a wound which is not free from germs. 

Germs or bacteria are the cause of inflammation in a wound and 
also of local or general blood poisoning. A clean wound, if not too 
much torn or bruised, will heal at once without the formation of 
pus or matter — providing that the cut surfaces be brought closely 
together. Such wounds, like the cuts made by surgeons, will require 
but a single dressing. If a wound, on the other hand, becomes con- 
taminated with germs, inflammation will set in, matter or pus will 
form, healing is slow, and all sorts of complications may ensue — even 
loss of limb or life. The three chief steps in the treatment of 

1 



WOUNDS— SPEAIXS— BRUISES 

wounds include: 1. Arrest of bleeding; 2. Cleansing, dressing, and 

covering the wound; 3. Securing rest of the injured part. 

In ordinary wounds and cuts not requiring special means to stop 

the bleeding, and Avhen stitching is not necessary or attempted, all 

that is essential is the swabbing of the wound with pure tincture of 

iodin, and application of sterile gauze and bandage. Apply the iodin 

on a pledget of absorbent cotton wound on the end of a toothpick or 

match. Instead of sterile gauze, clean cotton cloth boiled five minutes 

may be used. 

ARREST OF BLEEDING 

Bleeding is of three kinds: 1. From a large artery; 2. From a 
large vein ; 3. General oozing from smaller vessels. 

In general oozing the bleeding will stop naturally within a short 
time, in most cases, since the smaller cut blood vessels tend to contract 
and the blood in the ends of the cut vessels clots and plugs them. 

The bleeding from ordinary cuts and small wounds is of this 
kind. If the bleeding is considerable and does not lessen soon, a 
perfectly clean piece of absorbent cotton, or clean handkerchief or 
towel, may be dipped in water as hot as the hand will bear and pressed 
wet on the wound and held there for some time by a tight bandage. 
Clean ice water may be used in place of hot water where the latter is 
not obtainable. 

If the cut is on the arm or leg the limb should be held in the air 
resting on some object till the bleeding stops. The following remarks 
apply only to the treatment of severe bleeding. Where the bleeding 
is not severe, refer to page 8 for the further description of the 
care of wounds. Laymen are often frightened by the loss of small or 
moderate quantities of blood. When patients were bled it was not 
uncommon to remove from one to two pints of blood. 

Blood flows away from the heart in the arteries and is then under 
most pressure. It is of a bright color and spurts in jets each time 
the heart contracts. To stop such bleeding, pressure must be made 
over the cut artery on the side toward the heart. Blood flows from 
the extremities to the heart in veins. The blood is dark and flows 
continuously from a cut vein, not in spurts. To stop bleeding from a 
vein, pressure must be made over the vein on the side awav from the 



FIRST AID IN WOUNDS 3 

heart, or over the wound itself, as much less pressure is required to 
arrest the flow of blood. 

To Stop Bleeding When Bright Red Blood is Coming in Spurts 
from a Large Artery. — (a) Place the patient on his back and press 
with both thumbs into the soft parts just above the wound — that is 
between it and the heart. 

(b) While pressure is thus made above the wound, if of arm or 
leg, an assistant may tie a piece of elastic tubing or elastic suspenders 
very tightly about the limb between the wound and the heart. Or a 
piece of rope or strap may be wound tightly about the limb over a 
towel or shirt to protect the soft parts. Or a folded towel or handker- 
chief may be tied loosely about the limb and a stick used to twist 
up the slack so as to make a very tight bandage above the wound 
about the limb. A rounded stone or cork placed under the noose and 
directly over the bleeding vessel will still further aid. Then the 
pressure over the bleeding vessel with the thumbs may be removed 
unless the bleeding has not been arrested. The bleeding arm or leg 
should be also held up, resting on some sort of support, in order to 
keep the blood out of the limb. 

In case of a bleeding artery of any considerable size, the amount 
of pressure required to stop the bleeding will arrest the circulation in 
the limb and cause much pain and damage if it be continued for 
more than an hour. Therefore a surgeon should be summoned at 
the earliest moment to tie the vessel. In the meantime the wound 
should be painted with tincture of iodin, by means of a piece of 
absorbent cotton wound about the end of a moistened stick, and 
covered with a pad of sterile gauze or cotton and bandage, and the 
whole limb covered warmly and kept elevated till the surgeon comes. 
Any band tied tightly about a limb in order to stop bleeding from a 
large vessel is called a tourniquet. Those made for this especial 
purpose consist of a rubber band with hooks at the ends to fasten 
them together (Esmarch's), or the ordinary field tourniquet used for 
military purposes is composed of a band of webbing to which a pad 
is attached. After adjusting the pad over the bleeding vessel and 
tightening the band, the pad is more firmly pressed upon the vessel 
by means of an adjustable screw. 



4 WOUNDS— SPRAINS— BRUISES 

To Stop Bleeding from a Vein. Steady Flow of Dark Blood. 

— Make firm pressure with a pad of sterile absorbent cotton or gauze, 
or clean handkerchief wet with alcohol, placed directly over the 
wound. The pressure may be maintained by a tightly applied 
bandage over the pad where this can be used. The flow of blood in 
this case is from the extremities toward the heart so that a piece of 
rubber tube, elastic, suspenders, or handkerchief, may be tied about 
a limb on the side of the wound which is farthest from the heart to 
stop the bleeding. 

This is usually unnecessary, as pressure over the wound is com- 
monly sufficient to arrest bleeding from a vein. Neither is it ordi- 
narily necessary to tie even a large vein to stop bleeding, as in the 
case of a cut artery — providing the wound is tightly bandaged after 
it is dressed. 

After the first half hour the tourniquet (if one is used) about 
the limb may be taken off, and if the bandage is so tight as to inter- 
fere with the circulation it may be reapplied more loosely. 

To Stop Arterial Bleeding fro^i Special Parts of the Body 

Bleeding from the Scalp.— Cover the wound with a wad of sterile 
absorbent cotton or gauze, or a clean handkerchief or towel folded 
into a pad and saturated with alcohol, and press down the pad firmly 
over the wound. If this does not soon stop the bleeding a piece of 
rubber tubing may be tied tightly about the head below the wound. 
A large cord or small rope may be used in place of the rubber tube 
if tied over a folded towel to protect the skin. Pressure made by the 
thumbs of both hands just above and in front of each ear will compress 
the temporal arteries and tend to lessen the bleeding. 

Bleeding* from the Face and Neck. — Lip. — Bleeding from the 
cut lip may be stopped by holding the wounded part firmly between 
the thumb and forefinger. The hands should be thoroughly washed 
first. 

Carotid Artery. — The great vessel of the neck (carotid artery) 
may have been cut on the left side in attempted suicide, and by acci- 
dental means on either side. To stop bleeding from this vessel one 
should press with the thumb on the vessel below the wound in the 



FIRST AID IN WOUNDS 5 

neck. The place to make this pressure is about two inches below 
and one inch in front of the ear, where the beating can be plainly 
felt. Lower down in the neck the vessel is situated a little farther 
forward. The vessel should be pressed by the thumb, partly encir- 
cling the side of the neck, against the bones behind it. Of course 
this is but a temporary measure and the vessel must be tied by a 
skilled surgeon in order to permanently stop the bleeding from so 
large a vessel. 

External Jugular. — A large vein (external jugular) runs down 
the neck from back of the jaw to the middle of the collar bone and 
is more apt to be cut because it is nearer the skin. The blood would 
then be dark and in a continuous flow and not in jets as from the 
carotid artery. 

To stop such bleeding pressure should be made over the bleeding 
vessel just above the wound. In no case should a tight bandage be 
tied about the neck, as it would choke the patient. 

Bleeding from the Shoulder and Armpit. — This region is sup- 
plied by a large vessel (subclavian artery) situated behind the collar 
bone. As a temporary measure bleeding may be stopped, in injury, 
about the shoulder or armpit, by deep pressure exerted by the thumb 
behind the middle of the collar bone which forces the artery upon 
the first rib. Also bleeding in the armpit may be controlled by folding 
a clean towel into a pad, forcing it up into the armpit, and then 
binding the arm firmly to the side. 

Bleeding from the Arm, Forearm, and Hand. — There is one 
main artery (brachial) running down the inside of the arm, from 
the middle of the armpit to the middle of the bend of the elbow ; at 
the bend of the elbow it divides into two vessels, one of which 
(ulnar) runs down the little finger side, and the other (radial) runs 
down the thumb side of the forearm and is commonly felt at the 
wrist in taking the pulse. 

To stop bleeding from a wound in the arm or forearm, make a 
tourniquet and fasten it about the upper part of the arm. In a cut of 
the palm of the hand one should make a pad of two clean handker- 
chiefs or other cloth, and bandage very tightly over this and continue 
the bandage firmly up above the elbow. The hand should be then 



6 WOUNDS— SPRAINS— BRUISES 

kept elevated by tying it up to the head of a bed or other support. 

Bleeding from the Thigh, Leg, Foot, and Forearm. — Thigh — 
Knee — Forearm. — Here the application of a tourniquet to the upper 
part of the thigh will stop bleeding from an artery below this point, 
but in bleeding from the back (or bend) of the knee a folded towel 
may be placed in the bend of the knee and the knee bent as far as 
possible so that the heel will touch the thigh. Then the leg is held in 
this position by tying a bandage about the middle of the thigh and 
leg. The same method of controlling bleeding in the forearm may be 
applied by placing a pad in the bend of the elbow and then bringing 
the forearm as close to the arm as possible and holding it in this 
position by a bandage. 

Foot. — Bleeding from the foot may be stopped by placing a 
tourniquet tightly about the leg just below the knee. Also pressure 
with the thumb across the instep above the wound will control bleed- 
ing from a cut on the upper part of the foot, while pressure made 
with the thumb in the hollow just behind the inner prominence of the 
ankle bone (internal malleolus) will control bleeding from the sole 
of the foot. 

When bleeding can be stopped by simple pressure on a single 
vessel it is better than using a tourniquet around the whole limb, as 
hand pressure does less damage. But a tourniquet is desirable where 
the patient must be transported and where considerable time must 
elapse before skilled surgical assistance can be obtained. 

Bleeding after the Extraction of a Tooth. — This occasionally is 
persistent, and in order to stop the bleeding a plug of absorbent cotton 
or sterilized gauze saturated in a strong solution of alum — or better 
adrenalin solution (1 to 1,000) — should be forced into the cavity and 
held in place by keeping the jaws tightly together with a bandage 
tied over the head and under the chin. The plug may be soaked in 
strong tea, when the medicines advised cannot be readily obtained. 
Spitting and swallowing tend to favor bleeding and must be stopped. 
The head may be held to one side to let the saliva and blood flow out 
of the corner of the mouth. 

Bleeding from Varicose Veins in the Legs. — Enlarged or vari- 
cose veins are common in the legs, especially on the inside and back 



FIRST AID IN WOUNDS 7 

of the calves, where they stand out as bluish cords and knots. Con- 
siderable bleeding may result from the breaking of one of these veins. 
It may be readily stopped by causing the patient to lie down with 
the feet elevated on some object, and by placing a clean handkerchief 
or towel folded in a compress, over the wound, and holding this down 
firmly by means of a bandage applied from the ankle to above the 
bleeding point. The patient should remain quiet on his back for a day 
or more after the accident. 

Internal Bleeding 

Bleeding from the Lungs (Hemoptysis).— This is almost always 
caused by tuberculosis of the lungs. It is rather a favorable symptom 
in consumption unless the bleeding is copious. 

In 16 per cent, of consumptive patients hemorrhage is the only 
symptom, and no future trouble may develop. The blood is bright 
red and frothy, from a teaspoonful to a large amount, and often ac- 
companied by coughing. The chief aid that can be given a patient 
is to quiet him in body and mind. Make him lie down with the head 
raised ; do not allow him to talk ; and place a folded cloth wrung out 
in cold water over the front of his chest. Deep breathing lessens 
bleeding ; and three drops of spirit of turpentine given on sugar and 
repeated hourly for four doses is a good remedy. 

Bandaging the limbs, from the feet to the thigh, is useful in 
severe bleeding to keep the blood in the limbs and lessen the return 
flow of blood in the veins. ~No alcohol in any form should be given, 
but a dose of sixty grains of sodium bromid dissolved in a whole 
glass of water is very useful in diminishing fear, excitement, and 
cough. 

The patient should remain quiet in bed for many days after a 
severe hemorrhage, on a diet of milk, toast, cereals, and soft eggs. 

Vomiting of Blood. — The blood is bright red when the bleeding 
is copious ; otherwise it is black or rust-colored. The patient should 
be kept perfectly quiet and flat on the back with the head slightly 
raised. It is better to give nothing whatever by the mouth; alco- 
holic drinks are especially to be avoided. Most persons recover from 
the vomiting of blood without special treatment other than quiet, 



8 WOUNDS— SPRAINS— BRUISES 

rest, and abstention from food and drink for three days. One 
quart of water as hot as the hand will bear should be injected slowly 
into the bowel and repeated three times a day ; the heat tends to stop 
the bleeding from the stomach. When a physician cannot be reached 
to give morphin under the skin, one suppository containing one- 
half grain of the extract of opium should be placed in the bowel as 
soon as possible after the bleeding. This is the dose for an adult and 
opium is the most useful drug in relieving excitement, and so quieting 
the patient. 1 Small pieces of ice may be placed in the mouth to re- 
lieve thirst. After three days milk may be given every two hours. 

Severe bleeding from the stomach is commonly caused by ulcer 
of the stomach or bowels, or cancer of the stomach — when there has 
been a previous history of chronic indigestion. If there has been no 
such history then the bleeding arises from diseases of other organs, as 
the liver and heart. When blood has been swallowed in large quanti- 
ties, after injury to the head and in unconsciousness, it is likely 
to be vomited — but in these circumstances the vomiting of blood does 
not indicate diseases of the stomach. 

Bleeding from the Bowels. — When the bleeding is severe the pa- 
tient may suddenly fall down in a faint, and some hours after pass 
bright red or tarry-looking blood from the bowels. In case the patient 
has a previous history of indigestion it is probable that the bleeding is 
caused by duodenal ulcer, and such an attack is sometimes the first 
symptom of this disease. Bleeding from piles is bright red, and 
the amount at one time is not so great as to endanger the patient ; 
it occurs usually after or with a bowel movement. The treatment of 
severe hemorrhage from the bowels is the same as that for bleeding 
from the stomach. Hemorrhage from the bowels is one of the com- 
plications in typhoid fever. 

CLEANSING, DRESSING, AND COVERING THE WOUND 

The Immediate Care of Fresh Wounds.— Severe hemorrhage is 
arrested by the methods detailed. In ordinary cuts and wounds, in 
which the bleeding is slight or has been arrested, the chief object 
should be to free the wound from germs and keep them out. Prac- 

1 Opium is a powerful drug, sold only on a doctor's prescription. 



FIRST AID IN WOUNDS 9 

tically all wounds are contaminated with germs unless made with 
the surgeon's knife, when the skin and knife are first rendered germ- 
free. Slight cuts will heal without any special care in many cases 
because the tissues destroy a certain number of germs. It is safer 
to act as if all wounds were infected with germs. 

There are two ways to rid wounds of germs : one is by prolonged 
washing with boiled water or weak antiseptic solutions, the other is 
by the use of iodin without washing. Both methods are in use by 
leading surgeons, but the latter is more suitable for the layman. 
The iodin method is that in which reliance is placed on the action of 
tincture of iodin in penetrating the tissues and killing germs. No 
water should be employed at all in washing the skin or wound when 
iodin is used, because a surface wet with water prevents the penetrat- 
ing action of the iodin. When the skin is very dirty or greasy it is well 
to first wipe the skin about the wound with benzin, ether, or alcohol, 
and wait for its evaporation before applying the iodin. The wound 
should be protected meanwhile by holding a dry pad of sterile gauze 
over the wound while wiping the skin. Instead of pure tincture of 
iodin a solution prepared by diluting the tincture with an equal 
amount of alcohol should be used on the skin and wound, except in 
the case of small wounds. 

In the use of iodin, after any severe bleeding is checked and all 
foreign bodies picked out (as clothing, hair, splinters, glass, etc.) 
with a pair of forceps or hatpin which has been previously boiled, 
tincture of iodin is swabbed thoroughly into all parts of the wound 
by means of a piece of absorbent cotton which has been wound 
about the end of a moistened match or small stick of wood. The 
surrounding skin has also been swabbed over, as described. Then the 
wound may be either covered at once with sterile gauze or, if neces- 
sary, stitches may be used to close the wound and the tincture of 
iodin should again be swabbed over the stitches after they are tied. 
Some considerable smarting may be caused for a short time by the 
iodin. This method is wonderfully simple and effective and has 
largely superseded the older cleansing method in many hospitals. It 
is particularly applicable for a first aid dressing in fresh wounds 
for the layman, because no appliances are needed. Tincture of iodin 



10 WOUXDS— SPEAIXS— BRUISES 

should be kept on hand wherever surgical accidents are liable to occur. 
Two parts of alcohol and one part of water mixed together makes one 
of the best antiseptics for application to ordinary cuts, although not 
as powerful as tincture of iodin. 

When the iodin method is not used the attendant should boil some 
pieces of absorbent cotton, as large as an egg, together with a hand 
scrub brush, in an enamel hand basin of water for ten minutes. If the 
wound is large enough to require closing by stitches and one is to 
attempt this then black or white silk (cotton may be used) thread, 
needles, scissors, a folded towel and forceps should be boiled for ten 
minutes in the same basin. In the meantime the attendant should 
wash his hands for five minutes with soap and water and then with 
seventy per cent, alcohol, without drying his hands on a towel. An- 
other basin of clean, warm water containing one large-sized corrosive 
sublimate tablet, or three teaspoonfuls of compound cresol solution 
to the quart, should be prepared. If neither absorbent cotton nor 
antiseptics are at hand, one may use pieces of cotton cloth boiled in 
water which is allowed to cool sufficiently. In case the wound con- 
tains much dirt it is better to mix the antiseptic solution in a pitcher 
so that it may be poured with some force into the wound, thus acting 
more efficiently as a cleansing agent. When stitches are to be taken 
the needles should be threaded before boiling and, to prevent snarl- 
ing of the thread in boiling, the threaded needle should be run in and 
out through a strip of cotton cloth and the whole boiled. After 
boiling, the materials should be taken from the fire and the water 
poured off. Then the absorbent cotton should be placed in the anti- 
septic solution with the clean fingers or, better, boiled forceps. 

Any hair should be shaved off (this is not necessary when iodin 
is used) for several inches about the wound, and the skin about the 
wound washed with soap and water — clean water — and then alcohol 
(70 per cent.), while the wound itself is kept covered with a piece of 
sterile gauze or boiled absorbent cotton. All foreign matter in the 
wound, as splinters of wood, clothing, loose bits of skin, glass, etc., 
should be picked out with forceps or a boiled hatpin. Then the 
wound must be most thoroughly bathed with the antiseptic solution 
and cotton sponges. If there is much bleeding the antiseptic solution 



FIRST AID IN WOUNDS 11 

must be as hot as the patient will bear and all clots should be washed 
out. For this purpose, and in dirty wounds, the solution may be 
poured from a pitcher held a foot or so above the wound; in dirty 
wounds this washing should be continued from ten to twenty minutes. 
The wound should be covered with sterile gauze and bandage. If 
gauze is not available cotton cloth, which has been boiled five minutes, 
is satisfactory. That part of the gauze or cloth which will touch 
the wound must not be touched by the fingers. If, however, surgical 
assistance cannot be obtained for twenty-four hours and the wound 
is large an attempt should be made to close the wound by stitches. 

Stitching the Wound.— After the attendant has cleaned the 
wound (or painted it with iodin) and again washed his hands he 
should place the boiled towel about the wound so that the thread may 
lie on the towel and not become contaminated by touching the skin. 
Ordinary strong, straight sewing needles may be used when surgical 
needles are not obtainable. The needle is grasped between the thumb 
and forefinger or, better, by a surgical forceps. It is thrust in the 
skin about one-eighth of an inch from one cut edge of the wound and 
should not go deeper than the skin, and should leave the skin about 
the same distance from the cut edge on the other side of the wound. 

The stitches are placed about one-half inch apart, and are drawn 
together and tied in a square knot, cutting the ends about one-half 
inch from the knot. The stitches should be tied just tight enough 
to bring the edges of the wound together. If tied more tightly the 
thread will cut into the skin when the usual swelling occurs about 
the wound. During the stitching the thread, scissors, and forceps, 
should be laid only on the boiled towel. Large gaping wounds are 
more properly closed by stitches but it is wise to stitch the wound 
only in part, leaving an inch or so open for drainage. Small, deep, 
punctured wounds are not closed at all but should be kept sedulously 
open, after swabbing to the bottom with iodin, by pushing in a strip 
of boiled cotton cloth or gauze, to secure drainage. This may be 
removed in forty-eight hours. 

Sterilized catgut sutures may be used for closing wounds which 
come together readily. If there is much tension on catgut the stitches 
will not hold. Catgut has the advantage of being absorbed. 



12 WOUNDS— SPRAINS— BRUISES 

Adhesive Plaster. — Adhesive plaster may be used to close fresh, 
clean wounds and the layman can perhaps more easily employ it than 
stitches. Strips of plaster one-third of an inch wide, and long enough 
to obtain a good hold on the skin, should be laid at intervals of half 
an inch across the wound. The ends are applied to one side the 
wound and, while the edges of the wound are pinched together, the 
free ends of the strips are carried across the wound and fastened to 
the skin beyond. The strips of plaster should never wholly encircle a 
limb or the circulation would be impeded. 

Further Care of Wound. — When a clean wound is covered with 
sterile gauze and bandage, after stitching or closing with strips of 
adhesive plaster, the rule is not to disturb the dressings for a week 
unless the patient has fever, suffers pain, or the dressings become 
soaked through with blood or secretion. At the end of this time the 
stitches are cut with scissors and taken out by forceps or the fingers, 
after the attendant has thoroughly washed his hands in water and 
alcohol and boiled the instruments. Whenever the dressing becomes 
soaked through it should be replaced by a fresh dressing, although 
the layer of gauze next the wound may be left in place for three 
days or a week if there is no fever. If the wound is already infected 
at the time it is first seen, or becomes so, the stitches should be removed 
at once. Infection is recognized by the occurrence of pain, swelling, 
heat and redness about the wound, by fever (in large wounds), and 
the appearance of matter or pus. 

When there is much inflammation it is a good plan to apply a 
moist dressing until the inflammation has subsided. This is made by 
soaking sterile gauze in a warm, saturated solution of boric acid 
(as much as the water will dissolve), wringing out the water slightly 
with clean hands — being careful not to touch that part of the gauze 
which will come in contact with the wound. The wound is covered 
with this dressing an inch thick and then with a piece of oil silk or 
rubber cloth, which will keep the dressing moist for twenty-four 
hours, when the whole is covered with a bandage. Instead of boric 
acid a solution of corrosive sublimate or compound solution of cresol, 
in half the strength advised above for cleaning wounds, may be 
employed. 



FIRST AID IN WOUNDS 13 

Special Wounds 

Incised Wounds. — An incised wound is one made with a sharp, 
cutting instrument, as a knife, glass, razor, sword, etc. It is apt to be 
clean and to heal readily. In wounds of certain parts, as the wrist, 
the nerves and tendons are so near the surface that they are likely 
to be severed. Simply stitching the wound together will not cause 
union of cut nerves and tendons. Only a surgeon can properly repair 
such tissues, and one sees not infrequently a permanently disabled 
hand caused by the closure of a wound where injured nerves and 
tendons were not sutured — even by doctors. 

Lacerated and Contused Wounds. — These are caused by some 
blunt instrument and are apt to be contaminated with dirt, with much 
tearing and bruising of the tissues. They present a ragged appear- 
ance, do not bleed much, but will not heal readily. These are the 
wounds which may bo swabbed with iodin and not closed unless large, 
when they may be stitched in part. As they usually do not heal read- 
ily but form pus and become inflamed the use of the wet, antiseptic 
dressing of boric acid (see above) should be used from the beginning 
in extensive, lacerated, and contused wounds. In lacerated, contused, 
or punctured wounds antitoxin is often advisable to prevent lockjaw. 

Punctured Wounds. — Punctures are made with small instru- 
ments, as a nail, scissors, splinter of wood, knife, the tooth of a dog or 
cat. All such are peculiarly bad because they are generally infected 
by germs and the wound closes behind the withdrawing instrument 
and leaves the germs sealed in the wound. In punctures by very small 
sharp clean instruments, as needles, treatment may not be necessary, 
but in all other punctured wounds the skin about the wound should 
be cleaned by wiping with alcohol or ether, and the wound should 
be swabbed to the bottom with tincture of iodin on a piece of cotton 
wound on a small stick, as a toothpick. By moistening the wood in 
water, before twisting a wisp of absorbent cotton on its end, the 
cotton will adhere strongly to the wood and its escape in the wound 
will be prevented. It goes without saying that any foreign body in 
the wound should be withdrawn with forceps. 

Punctured wounds too small to sw T ab out should be opened ; but 



U WOUNDS— SPRAINS— BRUISES 

this cannot be done properly by a layman. Then the moist dressing 
of boric acid and gauze, described above, should be applied. It is 
well to stuff a piece of gauze or strands of boiled string in punctured 
wounds at the first dressing to aid drainage. This may be done with 
a piece of stiff wire (as a hairpin), which is smooth at the end, and 
which has been boiled five minutes. 

After dressing the wound the part should be kept at rest by a 
sling or splint. 

Scalp Wounds. — These bleed a good deal but the bleeding may 
be stopped by applying water as hot as can be borne, and then a wad 
of sterile gauze or boiled cotton should be placed in the wound and 
bandaged down tightly into it for a while. When the bleeding is 
stopped, or when there is not excessive bleeding, a wad of sterile 
gauze or cotton should be pressed down so as to cover the wound and 
arrest bleeding while the hair is cut for a considerable area about 
the wound. The wound and surrounding skin are then swabbed 
with the tincture of iodin and if possible the wound should be closed 
with stitches, as described above. The stitches will stop the bleeding 
more effectively than will anything else ; they should be tied loosely, 
and should be introduced as much as half an inch apart to allow drain- 
age of discharge from the wound. Apply a dry dressing of gauze, and 



Bullet Wounds. — These are produced by the shotgun, revolver, 
or rifle. In the case of the shotgun at long range the single shot will 
not generally do much harm unless it enters the eye. At close range 
a charge of shot, especially buckshot, acts as one missile and carries 
away a mass of tissue, or fingers, or toes, and makes a dreadful 
wound which is commonly fatal when any large vessel or cavity of 
the body is entered. In the treatment of injury by a single shot the 
wound should be swabbed with tincture of iodin and covered with 
sterile gauze, or cotton which has been boiled for five minutes, and 
bandaged. In case of wounds from a charge of shot at close range, 
treatment consists in stopping the bleeding by the methods described, 
trimming away ragged, loose bits of tissue, painting the wound and 
surrounding skin with tincture of iodin, or cleansing it with solutions, 
as has been set forth, to remove germs, and packing in loosely some 



FIRST AID IN WOUNDS 15 

sterile gauze or boiled cotton cloth to aid drainage. The dressing 
should be of sterile gauze. Lockjaw is to be feared following such 
wounds. 

Blank Cartridge and Toy Pistol Wounds. — These occur at 
close range and consist of burns and lacerations, with often a frag- 
ment of wad or clothing buried in the wound. Bits of the envelope' 
of the fulminate explosive in toy pistols are often driven far into the 
tissues. Lockjaw is especially to be dreaded in these wounds. The 
skin should be cleansed by wiping with alcohol or benzin (avoid fire) 
and foreign bodies should be picked from the wound, which must be 
enlarged if necessary, and then wound and skin should be swabbed 
with tincture of iodin and a few strands of string, which has been 
boiled five minutes, or a small strip of gauze, should be pushed into 
the bottom of the wound to secure drainage. The moist dressing of 
gauze and boric acid solution should be applied, and following this, 
a bandage. 

Revolver Bullet Wounds. — The bullet lodges in the tissues or 
perforates and escapes. The wound of exit is larger and the edges are 
turned out, while the wound of entrance is smaller and may be black- 
ened or tattooed by powder grains, in case of shooting at close range. 
There is usually not much bleeding. The future course of the wound 
depends largely upon the first aid dressing. The wounds should 
simply be swabbed with tincture of iodin, including an area two 
inches wide or so about the wound, and covered with a pad of dry 
sterile gauze and bandage. 

The wound should then be kept at rest by a splint or sling and 
by the patient remaining in bed. Probing for bullets is generally 
undesirable because of the danger of infecting wounds with germs, 
and it never should be undertaken by the layman. X-ray examination 
is the method by which the site of lodged bullets is determined at 
present. A bullet is not freed from germs by the heat generated in 
the weapon — although it is partly so freed, and also to a considerable 
extent by the scraping against the inside of the barrel of the weapon. 
There is danger of parts of the clothing (containing germs) being 
carried into the wound by the bullet. Bones more often deflect pistol 
bullets, while rifle bullets perforate or shatter them. A revolver 



16 WOUNDS— SPRAINS— BRUISES 

bullet may be so deflected by bone that it passes completely around 
the chest on a rib, or about the skull under the skin. 

A bullet that has become misshapen by striking a bone may 
produce a large and ragged hole where it emerges. There may be no 
pain, or only a stinging numbness may be felt by the persons shot. 
The dangers are bleeding, shock, and poisoning of the wound and body 
as a whole by germs, carried in by the bullet itself or by clothing. 
If a portion of the clothing has been carried into the wound there 
will surely be an infection of the wound. The bleeding is usually 
not dangerous because large vessels are often not injured or are 
pushed aside. If severe hemorrhage occurs it must be treated as 
recommended above. 

Shock may be so severe that the patient has profound depression 
and weakness, is pale, with cold extremities and skin, and weak, 
rapid pulse. The best treatment for the layman to pursue is to 
make the patient lie down and keep quiet. The wound should be 
swabbed with tincture of iodin and, when dry, a piece of sterile gauze 
should be applied and then a bandage. If there is much shock the 
patient should be given three tablespoonfuls each of whisky and 
water, he should be covered warmly, and should have hot water bags 
placed about him in bed. Healing of the wound rarely occurs at 
once, but more or less "matter" or pus forms owing to the destruction 
of tissue along the course of the bullet. In case the skull, chest, or 
abdomen are entered operation may be immediately required. It 
goes without saying that a surgeon should be summoned at the earliest 
opportunity in any case. 

Rifle Bullet Wounds. — In the army and some sporting rifles a 
lead bullet with a hard jacket of copper and tin is used. These tend 
to perforate the body and escape, leaving a comparatively small 
track, and wounds may heal immediately if properly cared for. 
Sporting rifle bullets with a soft nose spread in the body and tear 
the tissues so extensively that death usually follows, if the trunk or 
head are struck, and amputation becomes necessary if the limbs are 
shot. The hard, small, jacketed bullets of modern warfare do not 
generally shatter bone at distances over five hundred yards, but cut a 
clean hole through it. They do not make a large wound of exit 



FIRST AID IN WOUNDS 17 

because they are not much deformed in their passage through the 
body. Bits of clothing are not apt to be carried into the wound. 

At distances under five hundred yards the modern military rifle 
bullet shatters bone and causes tissue to explode, or burst asunder, 
so that the whole brain or abdominal organs may be practically 
destroyed. Tissues are not pushed aside as by a revolver bullet, but 
large vessels are cut as with a knife, and fatal bleeding may rapidly 
ensue. At distances of over one thousand five hundred yards the 
modern military rifle is a humane weapon. In some cases there have 
been practically no bad effects from perforating wounds of the lung, 
brain, belly, and joints. The bullet is not free from germs as some 
(not removed by the cleaning in the barrel and burning of the pow- 
der) adhere to the point. The tissues are but slightly lacerated, 
clothing is not carried into the wound, and the germs scattered along 
the track of the bullet are so few that the tissues can overcome and 
destroy them. 

In the Russo-Japanese war only thirty per cent, of the wounds 
among the Russians are said to have suppurated, or formed "matter." 
In the present great European War 95 per cent of the wounds are 
infected in soldiers living in the trenches — owing to their filthy 
clothes and skin. The symptoms and treatment of rifle bullet wounds 
are much the same as in the case of revolver bullets. Severe shock 
and bleeding are more common; they should be treated as already 
recommended. Unless these are very severe, or bone or vital parts 
greatly injured, it may happen that the first-aid dressing will be 
the only one necessary. 

Clothing should be cut away about the wound; the skin and 
wound should be painted with tincture of iodin; and when this is 
dry a sterile gauze pad of considerable thickness and a bandage 
should be applied, and the patient and wounded part kept at rest. In 
lieu of iodin the wound may be bathed with alcohol, or water 
which has been boiled. Where neither are obtainable the sterile pad 
should immediately be applied to the wound. 

The first-aid packet carried by U. S. A. soldiers contains two 
bandages, two compresses, and two safety pins in waxed paper in a 
metal case. The compresses are of corrosive sublimate gauze, and 



IS WOUNDS— SPRAINS— BRUISES 

one is sewed to the middle of each bandage which is so folded that 
the compress may be opened without touching with the fingers the 
surface which will come in contact with the wound. 

It will be seen that the iodin treatment of wounds is a great 
improvement in the matter of simplicity over the older method of 
cleansing with boiled water or antiseptics, as it avoids the necessity 
of sterilizing the hands, of boiling sponges, instruments, and water, 
and of fifteen minutes or more spent in washing. All that is neces- 
sary is a bottle of iodin, a stick, and some absorbent cotton to wind 
about it for applying the iodin; the results appear to be just as 
good with either method. Most surgeons now prepare the skin for 
operations by simply swabbing the skin with benzin, to remove grease, 
and then with tincture of iodin (diluted with an equal part of alco- 
hol) . The older procedure consisted in scrubbing the skin with soap 
and water for 10 minutes and then applying in turn various anti- 
septics. 

AFTER-TREATMENT OF WOUNDS 

All wounds should be kept at rest after they are dressed ; this is 
accomplished in the case of the lower limbs by keeping the patient in 
bed with the leg raised on a pillow. The same kind of treatment 
applies in severe injuries of the hands. 

In less serious cases a sling may be employed, and the patient may 
walk about. When the injury is near a joint, as of the fingers, knee, 
wrist, or elbow, a splint made of a thin board from a box or of tin 
(and covered with cotton wadding and bandage) should be applied 
by means of surgeon's adhesive plaster and bandage, after the wound 
has been dressed. In injuries of the hand the splint should be 
applied to the palm side and should reach from the finger tips to 
within two inches of the bend of the elbow. In injuries about the 
knee the splint should be of board four to five inches wide and 
three-eighths to one-half inch thick, and applied along the back of the 
leg from two inches above the ankle to half way up the back of the 
thigh. 

It is impossible in a work of this kind to describe the details of 
the after-treatment of wounds, as this can only be properly carried 
out by one with surgical experience, owing to the varying conditions 



FIRST AID IN WOUNDS 19 

which may arise. In general it may be stated that the same clean- 
liness and care should be followed during the whole course of healing 
as has been described for the first dressing. Iodin is not used, how- 
ever, after the first dressing. If fresh incised wounds are treated, 
as has been recommended, it is to be expected that they may heal 
by primary union, that is, heal at once without any other dressing. 
In such a case the dressing will not be removed until a week or ten 
days has elapsed, unless there is much pain about the wound with 
redness, heat, swelling, and formation of "matter." The stitches 
are not disturbed until ten days when they are cut with a scissors and 
pulled out with dressing forceps, the instruments having first been 
boiled for five minutes and the hands of the attendant washed. The 
instruments are kept in the basin in which they are boiled, and the 
hot water is poured off. 

Wounds require daily dressing when they do not heal at once but 
become more or less inflamed and form pus or "matter." If stitches 
have been used they should be taken out as soon as "matter" forms, 
or the parts about the wound become much reddened, swollen, and 
painful. Then a dressing of gauze wet in boiled water (containing 
as much boric acid as it will dissolve, or compound lysol solution, or 
corrosive sublimate) should be applied and covered with oiled silk or 
rubber cloth and changed once daily. If there is much pus the 
depths of the wound should be syringed with boiled water or one of 
the solutions just mentioned. 

This treatment should be pursued until the pain and inflammation 
subside and then the treatment should be changed to the daily cleans- 
ing of the wound, as just described, followed by the application of 
just enough Peruvian balsam to cover the wounded surface, dry 
gauze, and bandage. This latter treatment is also suitable from the 
beginning in wounds which form pus but are not painful or much 
inflamed. Some sterile or borated vaselin in tubes is very useful if 
sufficient is squeezed out of the tube each day to cover the wound — 
after application of the Peruvian balsam, the vaselin makes the 
wound much more comfortable and prevents the gauze from sticking 
to it. When there is little discharge or pus, the skin about the 
wound may merely be wiped off with alcohol on a piece of absorbent 



20 WOUNDS— SPRAINS— BRUISES 

cotton ; some hydrogen dioxid is poured on the wound from the bottle, 
and the froth gently wiped from the wonnd by a piece of sterile 
gauze. The wound is then covered with Peruvian balsam, vaselin, 
gauze, and bandage. This is the simplest and best method of treating 
ordinary, moderate-sized wounds, and it avoids the necessity of 
making any solutions and boiling a syringe or instruments. 

It is a surgical maxim never to be neglected that wounds should 
not be allowed to close at the top before healing is completed at the 
bottom. As wounds tend to close at the surface when they heal slowly 
and discharge pus, it is necessary at times to enlarge the external 
opening by cutting or stretching with the blades of a pair of scissors 
(first boiled five minutes), or — and this is much more rational and 
comfortable for the patient — by daily packing the outlet of the wound 
with gauze, to keep it open. The attendant should always wash his 
hands before dressing a wound and not touch the wound itself or the 
dressings with his fingers. 

If the wound is to be washed or syringed some pieces of absorbent 
cotton, a glass syringe, forceps and scissors should be boiled in a 
basin five minutes. Then the boiling water is poured off and, when 
cool, the sponges are held with the forceps while washing the wound 
with an antiseptic solution, which has been placed in another basin. 
The same is syringed on the wound. Then the gauze is cut with 
the boiled scissors and placed on the wound with the boiled forceps. 
When instruments are not available that part of the dressing which 
touches the wound should not be touched with the fingers. 



LOCKJAW 
[Tetanus) 

This is a very terrible and often fatal disease exhibiting at first 
stiffness of the neck and muscles of the jaw, so that swallowing be- 
comes difficult or impossible, to be followed later by rigidity of the 
muscles of the trunk, and convulsions. 

The cause of the disease is a germ which lives in dirt, especially 
stable dirt and street dirt, and in garden soil and dust from walls. 



LOCKJAW 21 

walks and cellars. It is thought that tetanus germs live in the intes- 
tines of animals and hence the danger from manure and stable dust. 
The germ always enters the body through a wound or abrasion of 
the skin or mucous membranes, although either may be so small 
as to be imperceptible. Lacerated and punctured wounds of the 
hands and feet, especially if made with a stable fork or splinter from 
a stable floor, or by a toy pistol or firecracker used in Fourth-of- July 
celebration, are most liable to cause lockjaw. The germs of lockjaw 
grow best in the absence of air so that punctured wounds, and those 
filled with pus, into which air cannot enter freely, are most favorable 
to the development of the disease. 

Lockjaw is more common in certain regions, as in Northern New 
York, Long Island, Virginia, Pennsylvania, Georgia and Louisiana. 

Prevention. — Prevention of the disease when due to wounds is 
of the greatest importance because it can be successfully carried out. 
Prevention is obtained first by properly opening and sterilizing 
wounds with iodin, and keeping them open with a strand of gauze 
for drainage, as described under punctured wounds. Then the injec- 
tion of tetanus antitoxin is advised in such injuries as Fourth-of- 
July wounds or punctured or lacerated wounds of other parts, espe- 
cially of the hands and feet, into which dirt has entered. This is 
particularly desirable in localities in which lockjaw is prevalent. 
The use of antitoxin at the time of the injury, or within a day or so 
afterward, is an almost certain preventive of tetanus and is attended 
with no danger to the patient. Thus in St. Louis in 1903, there 
were fifty-six cases of Fourth-of-July wounds, followed by sixteen 
cases of lockjaw, in none of which was tetanus antitoxin used as a 
preventive. In the following three years there were two hundred 
and ninety-one cases of Fourth-of-July injuries treated with antitoxin 
and not a single case of lockjaw followed. The wounds producing 
lockjaw usually have occurred in boys who have exploded blank 
cartridges in the palm of the hand. In this way the germs of tetanus 
in the dirt on the skin are forced into the wound, together with a 
portion of the wad from the shell. 

Since lockjaw has been so frequent after these accidents it is 
impossible to exert too much care in treatment. The wound should 



e? WOUXDS— SPRAINS— BRUISES 

be opened to the very bottom, under ether and by a surgeon, and not 
only every particle of foreign matter removed but all the surrounding 
tissue should be thoroughly sterilized. Then a dose of antitoxin 
should be injected under the skin. When, in spite of the use of anti- 
toxin, tetanus has occurred it has been of a mild character. Proper 
restriction of the sale of explosives will put an end to this awful 
result of a barbarous mode of exhibiting patriotism. The dangers 
of tetanus are among the chief reasons for the "safe and sane Fourth." 



SPRAINS 

A sprain is an injury caused by a sudden wrench or twist of a 
joint, producing a momentary displacement of the ends of the bones 
to such a degree that they are forced against the capsule or mem- 
brane surrounding the joint and the ligaments which bind the bones 
of the joint together, tearing one or both to a greater or less extent. 

The joints more often sprained are the ankle, the wrist, the 
fingers, the elbow and knee ; less often, the shoulder, the sacro- 
iliac joint, and the hip. The young and adults with flabby muscles 
and relaxed ligaments are more frequently the victims. The damage 
to the parts holding the joints in place may be of any degree from 
the tearing of a few fibers of the membrane (capsule) enwrapping 
the joint to its complete rupture, together with that of the ligaments, 
muscles, tendons, blood vessels, and nerves surrounding the joint, 
so that the bones are no longer in place, the joint losing its natural 
shape and appearance ; we have then a condition known as dislocation. 
In a sprain the twist of the joint produces only a momentary dis- 
placement of the bones forming the joint, sufficient to damage the 
soft parts around it, but not sufficient to cause lasting displacement 
of the bones or dislocation. 

It will be seen that whether a sprain or dislocation results 
depends upon the amount of injury sustained. Since it often happens 
that the bones entering into the joint are broken (sprain fracture), 
it follows that whenever there is produced what appears to be a 
severe sprain with inability to move the joint and great pain and 



SPRAINS 23 

swelling, it is important to secure surgical aid promptly. Many of 
these cases are found to be indeed fractures with sprains when they 
are examined by the x-ray. This is the only way by which even the 
most skillful surgeon can in many cases diagnose a fracture in 
injuries to joints because the great swelling obscures the ordinary 
signs. 

Symptoms. — The symptoms of sprain are sudden. They are 
severe pain in the injured part, and are often accompanied by swell- 
ing, tenderness, and heat in the joint ; faintness and nausea are fre- 
quently present. The sprained joint can only be moved with pain 
and difficulty. The swelling is due not so much to leaking of blood 
from broken blood vessels as to filling of the joint with fluid (serum) 
caused by inflammation. In severe sprains, however, the skin about 
the injury becomes "black and blue" from actual escape of blood 
from the torn blood vessels. In a badly sprained ankle the skin 
may be thus discolored almost up to the knee. 

One should always try to discriminate between a dislocation, a 
break of bone, and a sprain. Usually in a sprain affecting the 
ankle, hip or knee the patient can walk a little, whereas in case a 
bone is actually broken this is commonly impossible. In fracture 
into a joint there is usually more motion than there should be when 
the joint is moved by another person. In dislocation the form of the 
joint is altered and the joint is immovable by the patient. The 
layman can but guess at the diagnosis. 

General Treatment. — Since the treatment of severe sprains de- 
mands first of all discrimination between dislocation, a break of 
bone into a joint, or a true sprain with rupture of a ligament, 
capsule, or tendon of muscle, it follows that the methods herein 
described should only be followed in unmistakable sprains, or until 
a surgeon can be obtained, or when one is unobtainable. Xothing 
is better than immersion of a sprain for half an hour or more in 
water as hot as the hand will bear. 

Following this one may apply strips of surgeon's plaster to the 
part, as described below, or an elastic flannel bandage cut on the bias 
about three and one-half inches wide may be applied from the toes 
or finger tips snugly well up the limb some distance above the injured 



U WOUNDS— SPRAINS— BBUISES 

joint — the idea being to prevent swelling by keeping blood out of the 
part and to limit motion of the sprained joint. 

In bandaging there is danger of swelling later, with increased 
pain, coldness, and blueness of the fingers or toes below the bandage, 
owing to too tight a bandage. The bandage must then be removed 
and reapplied with less force. 

SPRAIN OF THE BACK 

{Sacro-iliac Sprain) 

This sprain occurs in the lower part of the back at a point about 
two inches to the right or left of the center of the spine and about 
two inches below the upper border of the hip bone behind. 

Its discovery has been comparatively recent and the condition is 
commonly called lumbago or sciatica, and may lead to incapacity for 
a life-time — if untreated — while treatment commonly relieves the 
trouble at once. 

The sacro-iliac joint is made up of the union of the lower bone 
of the spine (sacrum) with the hip. The lower bone of the spine is 
here expanded into two horizontal bony wings which are mortised 
into corresponding depressions in the hip bone, thus supporting the 
whole trunk above this point. There is a similar joint then on each 
side of the spine. 

The sprain is caused by falls, blows, and twists, by stepping from 
an unexpected height, and by lifting heavy weights. Pregnancy 
and labor in women may sprain the joint. Resting on a flat table on 
the back may cause the sprain during surgical operations. It may 
occur in those with relaxed muscles and with nervous prostration. 

Symptoms/ — Tenderness and pain are complained of about the 
joint at one of the points noted above. The pain is not limited to 
this region but is often felt in the groin and lower belly, down the 
leg behind and across the lower back. The pain or discomfort may 
be felt whether standing, sitting or lying, and especially on changing 
positions. The particular signs are those elicited by bending the 
body forward (the arms hanging down until the fingertips touch the 
floor) with the legs held together and without bending the knees ; 






SPRAINS 25 

also in bending the body from side to side in the same position. Or 
in lying flat on the back and holding each leg in turn straight in the 
air without bending the knee. In strain of this joint pain will be 
felt at once at the location of the joint on going through these tests. 
This may best be discovered by having another person press the 
thumb on the location of the joint while the patient goes through 
these motions. It is usual that only one joint is sprained, and then 
the pain is located more to one side of the back; occasionally both 
joints are sprained. In sacro-iliac sprain the body is apt to be 
arched toward the sound side and the shoulder lowered on the 
sprained side when the patient stands without clothing and is looked 
at from behind. 

In lumbago there is no tender spot over the sacro-iliac joint, the 
pain is more general over the back and on both sides, the pain and 
tenderness are higher, above the hip bone, and pain is chiefly felt 
on getting up and sitting down, or standing, and not so much in lying 
quietly on the back. In sciatica there is tenderness over the middle 
of the upper and back part of the thigh instead of over the sacro- 
iliac joint. 

Treatment. — The treatment usually has a remarkable curative 
effect. This consists in winding about the whole lower part of the 
body two-inch strips of zinc oxid adhesive plaster. Each strip over- 
laps the previous one half its width so as to make a thicker band. 
The ends meet in front in the lowest part of the belly and it may be 
necessary here to shave off the hair first. The first strip should be 
the lowest one and should be begun behind just above where the 
crease between the buttocks stops. One end of this strip is carried 
around to the middle line of the lower belly and the other end is 
drawn tightly across the lower back and about the other side and 
front of the belly to meet the first end. The whole width of the 
encircling plaster should be at least six inches from above the crease 
in the buttocks behind, but the ends may be overlapped in front so 
as to make a narrower band there. The plaster should be worn two 
weeks and replaced if necessary by a fresh one. Sometimes it is 
necessary that a canvas belt or plaster of Paris cast be fitted by a 
surgeon in order to secure a permanent cure. It is a disease which 



26 WOUNDS— SPRAINS— BRUISES 

requires skilled care where a surgeon can be obtained but one may 
obtain speedy and real relief by applying adhesive plaster as recom- 
mended. Soaking the plaster with alcohol or benzin will aid in its 

removal. 

SPRAIN OF THE HIP 

A true sprain of the hip is rare, as the joint is so well protected 
by powerful muscles. Bruises on the hip are common. In the case 
of any severe lameness and disability of the hip joint following an 
injury one should always think of a fracture in adults over middle 
age. In children tuberculous disease of the hip is commonly the 
cause of lameness in this joint. 

Symptoms. — There is tenderness in sprain of the hip felt on 
pressure with the thumb just back of the most prominent upper and 
outer part of the thigh bone (great trochanter) on the outside of 
the hip. 

Treatment. — In case of bruise or sprain of the hip the best treat- 
ment consists of rest in bed and the application of towels wrung out 
in hot water over the joint. These should be covered with a piece 
of oil silk or rubber cloth and then kept warm by means of a hot 
water bag. After a few days the leg should be moved in various 
directions while lying in bed and then the patient should be made 
to stand on his feet as soon as possible to avoid stiffness — especially 
in the case of old persons. 

SPRAIN OF THE KNEE 

This is caused by blows and falls as well as by a twist or strain ; 
in other words it may be in reality a bruise or contusion as well as a 
sprain in the true sense of the word. The actual condition is much 
the same in either case. It is popularly called "water on the knee." 

Symptoms. — There is swelling of the knee joint, increased heat 
to the sense of touch, tenderness, especially on each side of the knee- 
pan, stiffness and pain on motion — particularly if the leg is bent on 
the knee as far as possible. The swelling is due chiefly to an 
increase of fluid in the joint so that soft swellings appear on either 
side above the knee-pan; the knee-pan itself appears to float and 
can be pushed down on the joint so as to touch the bone by a sudden. 



SPRAINS 



27 



quick motion of the thumb. This can only be done properly when 
the patient is lying flat on his back with the legs out straight and 
relaxed. 

There are some conditions which should be distinguished from 
simple sprain or bruise of the joint. In case a portion of the cartilage, 
which acts as a sort of washer between the bones of the joint, becomes 
broken the patient will usually be aware of a floating body in the 
joint and may be able to 
see it and feel it at the 
side of the joint. There 
may be great swelling but 
little pain or lameness. 
When a whole cartilage 
gets displaced, the joint is 
suddenly locked in walk- 
ing and this is followed 
by swelling and lameness 
for a few days. 

Treatment. — In a se- 
vere sprain one of the 
(lateral) ligaments, bind- 
ing the bones together at 
each side of the joint, may 
be torn. In this case, the bones entering into the joint have more 
movement from side to side than they should. In moderate sprains 
the joint may be strapped with adhesive plaster as shown in Fig. 1. 
The strips of plaster an inch wide are drawn tightly across the joint 
in a diagonal direction. The plaster should reach about five inches 
above and below the joint and be brought around on the sides, but one 
should leave a space two inches wide behind the joint not covered 
with plaster — that is, the ends of the plaster behind the joint should 
not meet by two inches so as not to constrict the leg and shut off the 
circulation. Immediately after the injury the plaster is applied and 
the patient should rest in bed with an icebag over the knee until the 
following day, when he may walk about. In very severe sprains 
with much swelling and pain the patient should remain in bed with 




IG. 1. 



-Method of Strapping a Knee. (After 
Donahue's "Manual of Nursing.") 



28 WOUNDS— SPRAINS— BRUISES 

a splint on the back of his leg. as recommended for broken knee-pan. 
with an icebag on the knee continuously until the soreness and heat 
have departed. Then the adhesive plaster may be applied and the 
patient may go about on crutches. The plaster should be removed 
if it stretches and fresh plaster applied, unless recovery has taken 
place. Sometimes sprains of the knee are treated by bandaging the 
joint with a flannel bandage, cut on the bias, four inches wide and 
fifteen feet long, or a rubber bandage may be used. 

The bandage is removed once or twice daily for massage. 

SPRAIN OF THE ANKLE 

Symptoms. — In sprain of the ankle the foot is commonly turned 
in. Avith rupture of a part of the ligaments on the outside of the 
ankle joint: there is a special point of tenderness on pressure in 
front and below the bony prominence on the outside of the ankle. 
The ankle at once swells : there is great pain and inability to walk ; 
and, in a day or two, blue and later green and yellow discoloration 
of the skin is seen, due to blood escaping from ruptured vessels. 
When this discoloration is particularly marked a fracture of the 
tip of the outer bony prominence (malleolus) of the ankle should 
be suspected and a surgeon's aid should be sought. An x-ray picture 
will solve doubts as to fracture. 

Treatment. — The older treatment consisted in the use of hot 
water and bandaging, as described under the general treatment of 
sprains, but the writer for years has found immediate strapping with 
adhesive plaster very successful. Two strips of adhesive plaster 
twenty-eight inches long and two inches wide are prepared. The 
end of one of these is attached to the skin on the outside of the leg 
just below the knee : the plaster is then pressed against the whole of 
the outer side of the leg straight down to the heel : the free end is 
drawn as tightly as possible under the heel and up as far as it will go 
on the inside of the leg. The other strip is applied in just the same 
manner as the first, but on top and half overlapping it. This stirrup- 
like plaster prevents the ankle from bending from side to side. When 
it is applied the foot is held in just the position it would assume in 
standing upright with the inner borders of the feet in contact. It is 



SPRAINS 29 

well to shave off the hair and bathe the leg with soap, warm water, 
and then with alcohol, before applying the plaster — the leg must be 
perfectly dry or the plaster will not stick. To increase the protection 
to the ankle, strips an inch wide should be applied so as to encircle 
the heel, the ends crossing on the top of the foot and reaching the 
base of the toes. The first strip is applied lowest down on the heel, 
the second half overlapping the first and so on upwards like the 
shingles on a roof. The plaster should be continued well above the 
ankle but here it should not be applied too tightly or, if swelling oc- 
curs and the plaster be- 
comes too tight, it may 
be split right down the 
front of the ankle with 
blunt-pointed scissors. 
The author has found 
it safest in applying the 
plaster for the first time 
immediately after the , 

accident not to cross the Fig. 2.— A Good Method of Strapping a Sprained 
j j> ,-, -, Ankle with Adhesive Plaster. 

ends 01 the plaster on 

top of the foot and on the front of the ankle, as shown in Fig. 2, but 
to cut the plaster so that the ends will exactly meet in front of the 
ankle and on top of the foot ; then, if more swelling occurs, the ends 
of the plaster simply separate. 

In very severe sprains it is recommended that the patient remain 
in bed and soak the ankle for one-half hour in a pail of very hot 
water at two or three hour intervals. Between these soakings a 
flannel bandage wet in hot water may be applied to the ankle and 
kept hot by the use of a hot water bag, while the foot is kept raised 
in bed on a pillow. Then after forty-eight hours of this treatment 
the surgeon's adhesive plaster may be applied to the ankle, as just 
described. But in most cases the plaster may be put on as soon as 
possible after the accident and a hot water bag or an icebag may be 
applied to the ankle over the plaster for the first twenty-four hours, 
while the patient remains in bed. 

Walking should be encouraged after the first day as it hastens 




30 



WOTTXDS— SPRAINS— BRUISES 



recover^". Formerly it was the custom, after treatment with heat 
and rest for a few days, to place the ankle in a plaster of Paris cast 
and keep it thus for several weeks. At the end of that time many 
more weeks were required to rid the patient of the stiffness caused 
by this method. Now it is possible for patients to go about with a 
sprained ankle, after the first day, with the help of a crutch or cane 
for a few days. The plaster should be removed and replaced every five 
days or so and this should be continued for two weeks; it may be 
easily torn off, especially after soaking in gasoline, but this is as a 
rule not necessary, as it comes away in one piece. After the plaster is 
permanently removed stout tight-fitting lace boots should be worn and 
laced snugly to hold the ankle as in a splint. 



SPRAIN OF THE FINGERS OR THUMB 

This is produced by a strain of the ligaments binding the bones 
to each other, or by a blow forcing the ends of two bones together. 
In the latter case most pain is produced when the bones of the injured 
joint are pressed together. 

Symptoms. — There is swelling from increase of fluid in the 
joint, pain, and heat, and difficulty in moving the joint. 

Treatment. — Plaster strips one-half inch wide for the fingers 

and one inch for the 
thumb, are applied, 
as in Fig. 3. The 
finger or thumb may 
be held partly bent — 
this is the easiest po- 
sition. The strips are 
put on alternately 
from right to left and 
from left to right, so that they shall cross each other nearly at a right 
angle. If the bandage becomes too tight it may be slit up the whole 
length on the under side of the bandage with blunt-pointed scissors. 
The joint should be moved as soon as possible to prevent stiffness, 
and the plaster, while supporting the joint, will allow of sufficient 
movement. 




Fig. 3. — Adhesive Plaster Strapping for Sprain of the 
Thumb. 



SPRAINS 31 

SPRAIN OF THE WRIST 

In sprain of the wrist Colles' fracture should at once be thought 
of and any severe sprain of the wrist should be subjected to x-ray 
examination to eliminate the possibility of fracture of one or more of 
the small bones forming this joint. 

Treatment. — A mild sprain may be treated by wrapping adhesive 
plaster about the wrist joint from the base of the thumb up the arm for 
three inches. Plaster strips an inch wide should be made to wholly 
encircle the wrist ; one strip should overlap half the width of the strip 
preceding. Great care must be exercised not to apply the plaster 
tightly or the circulation in the hands and fingers will be impeded. At 
any time when this occurs the plaster should be cut straight up the 
front of the wrist with a pair of blunt-pointed scissors. In severe 
sprains the wrist should be soaked for half an hour in water, as hot as 
the hand will bear, and then a padded board one-fourth of an inch 
thick and a little wider than the arm should be applied to the palm 
surface of the hand, from the base of the fingers to within two inches 
of the elbow, by adhesive plaster and bandage, as for Colles' fracture. 

This may be removed twice daily for soaking of the wrist joint 
in hot water and massage. The forearm and hand should be carried 
in a sling. 

SPRAIN OF THE ELBOW 

A surgeon's advice should always be obtained in apparent severe 
sprains of the elbow. It is impossible to form a correct idea of 
severe injuries of this joint without the use of the x-ray. 

Treatment. — In sprains the immersion of the joint in hot water, 
as for the ankle, the bandaging with a flannel bandage carried from 
the wrist above the elbow, the use of a hot water bag or icebag in bed, 
and a sling when up and about, constitute the proper treatment at 
first; later moving the joint, bathing first in cold and then in hot 
water, and massaging with some liniment, are advised. 

SPRAIN OF THE SHOULDER 
Symptoms. — Under the large muscle (the deltoid) covering the 
outside of the shoulder is a sac (or bursa) the size of the palm of the 



32 WOtWDS— SPRAINS— BRUISES 

hand and containing fluid. This is often inflamed by blows and 
injuries which cause swelling on the top of the shoulder and tender- 
ness at the joint of the shoulder. Pain is especially felt when the 
arm is raised at a right angle with the body.' or when the elbow is 
bent at a right angle and the hand is moved out away from the body. 
The pain may be felt in the outside of the arm or even in the hand, 
as well as in the shoulder. 

Treatment. — The patient should at first rest in bed with the arm 
stretched out on a pillow at right angles with the body ; also painting 
the shoulder at one sitting with tincture of iodin. until it is stained 
very dark, will be of service. When sitting the arm should be held 
on a pillow on a table at right angles with the body so as to relax 
the shoulder muscle. 

Cases usually recover without operation but occasionally removal 
of the sac is necessary. This condition is, strictly speaking, a bursitis 
and not a sprain. 

BRUISES 
Contusions) 

A bruise is a hidden wound: the skin is not broken. It is an 

injury caused by a blunt instrument, as a punch with the fist or 

kick of the foot of man or beast. The skin may remain intact while 

the softer parts beneath are torn and crushed to a greater or lesser 

"extent. 

Symptoms. — The tearing of the smaller blood vessels causes the 
blood to escape under the skin and gives within a few hours the 
' "black and blue" appearance common to bruises of any severity. In 
bruises of deeper parts this coloration may not appear for several 
days. Sometimes large collections of blood (hematoma) form under 
the skin owing to blows and give rise to considerable swellings. These 
occur on the scalp, under the breast, tinder the skin of the ear, etc. 
The use of the bruised part is temporarily limited. Pain, faintness, 
and nausea follow severe bruises and, in case of bad bruises of the 
abdomen by a kick of a horse, or wheel passing over the body, death 
may ensue from rupture of the internal organs and from fatal 



SPRAINS 33 

bleeding internally. Furthermore, the bruise may be so great that 
the injury to muscle or nerve may lead to permanent loss of use of 
the part. For this reason a surgeon's advice should always be 
sought in cases of bad bruises. Pain is present in bruises owing to 
tearing and stretching of the smaller nerve fibers, and to pressure on 
nerves from swelling. The swelling is due to escape of blood and 
fluid from torn blood vessels. 

Treatment.— In severe bruises, with faintness and nausea, the 
patient should be made to rest flat on his back, be covered warmly 
and be given two or three tablespoonfuls of whisky in twice as much 
water. Rest of the injured part is essential, together with compres- 
sion, to prevent bleeding, inflammation, and swelling ; elevation of an 
injured limb also assists the same end. The snug application of a, 
flannel bandage cut on the bias is one of the best methods of treat- 
ment. In severe bruises and in the care of bruises in the aged, we 
use heat; in moderate bruises cold is more effectual at first. An 
icebag may be kept on the bandaged part held elevated on a pillow. 

When a part cannot be bandaged, or before it has been band- 
aged, the application of a cold compress in moderate bruises is 
advisable. Two layers of old cotton or linen are wet in ice water 
and laid on the part, or alcohol and ice water are used in equal 
parts. As soon as the compress grows warm it should be replaced 
by another cold compress. In severe bruises and when cold is 
unavailable or unpleasant to the patient, several layers of flannel 
are wrung out in very hot water and applied to the injured part cov- 
ered with oil silk or rubber. If a hot water bag is laid on the wet 
compress the heat will be long sustained — otherwise the compress will 
require constant renewal. 

What is known as cataplasma kaolini is an excellent remedy for 
bruises when spread hot and thickly over the injured part and covered 
with a bandage. When the inflammation is subsiding an ointment 
containing twenty-five per cent, of ichthyol is a useful remedy, 
together with bandaging. Following severe bruises the damaged 
parts should be kept warm, as described, or by covering them with a 
two-inch layer of absorbent cotton and bandage until surgical advice 
may be obtained. When the pain and swelling begin to subside 



34 WOUNDS— SPKAIXS— BBUISES 

in bruises, rubbing with liniment of ammonia is of service, and 
moderate exercise of the part is desirable. A bruise on a finger or 
toe-nail, sufficient to cause tbe parts under the nail to become bluish- 
red, may be very painful. In such a case the cutting of a narrow 
notch directly through and across the base of the nail sufficient to 
let out the blood is the proper treatment. A sharp jackknife, which 
has been boiled five minutes, may be used after the nail is washed 
with alcohol. The nail is raised from the soft parts beneath by blood, 
so that as soon as the nail is cut through the blood will escape. A 
piece of sterile gauze or boiled cotton cloth should be used to cover 
the wound in the nail for several days, by means of a bandage. 

In bruises of the testicles there is apt to be considerable swelling 
and pain. The parts should be supported while the patient is in bed 
by a folded towel placed across the thighs under the scrotum. Then 
a mixture of equal parts of alcohol and water should be used to wet 
a handkerchief or soft cotton or linen, two layers in thickness. This 
compress should be kept on the injured parts and moistened as often 
as dry, or an icebag should be laid over the testicles. 

When the patient is up an ointment containing twenty-five per 
cent, of ichthyol should be rubbed on the parts, and the testicles sup- 
ported by a suspensory bandage which is kept by all druggists. 

It may be necessary for a surgeon to let out large accumulations 
of blood caused by bruises on the scalp, ear, breast, etc. 

ABRASIONS 

When the surface is scraped off, as often happens to the shin, 
knee, head or hands, it should be covered with boric acid ointment 
or borated vaselin and a bandage. When the amount of skin re- 
moved is small and the part cannot be conveniently bandaged there 
is no better remedy than the compound tincture of benzoin which 
forms a coating over the part and is a powerful antiseptic. This is 
particularly useful when the knuckles are skinned, and for cracks 
on the skin or lip. It may be applied several times daily by wetting 
the cork of the bottle containing the benzoin. 



BRUISES 35 

SMALL CUTS 

After a small cut made by a sharp instrument stops bleeding, 
and the skin about it is dry, the best form of treatment consists in 
covering it with collodion. The collodion may be applied by means 
of a small stick, as a toothpick or match with the head broken off. 
Collodion is not suitable for abrasions as it will not stick to moist 
surfaces and causes great smarting on raw parts. 



CHAPTEK II 
DROWNING— ELECTEIC SHOCK— POISONING BY GASES 

DROWNING 

RESTORING THE APPARENTLY DROWNED 

Take great care of the patient where he is landed or he will 
freeze. No time must be lost. Wipe of! the nose and mouth and 
rip open the clothing about the chest and waist; separate the jaws 
and keep them apart by a cork or bit of wood ; turn the patient on 
his face, having placed a large bundle of clothing under his stom- 
ach. Press heavily on the back over the stomach to squeeze all water 




Fig. 4. — Expelling Watek from the Stomach and Lungs. (After Doty's "Prompt 

Aid to the Injured.") 



out of the stomach and lungs, continuing as long as water flows 
freely from his mouth (see Fig. 4). Then turn him on his back 
and wipe away any discharge from the nose and mouth with the 
fingers. Place a pillow, or folded clothing between the shoulders, 

36 



DROWNING 37 

and pull out the tongue. If there is nobody to hold the tongue 
out by means of a handkerchief wrapped around it, tie a string or 
strip of a handkerchief around the tongue and outside of the lower 
jaw to keep it from falling back. Or the tongue may be held be- 
tween the teeth by tying a handkerchief under the chin and over 
the head. Next, while kneeling at the patient's head and facing 
his feet, grasp the patient's arms at the elbows and lift his arms 
upward until they touch the sides of his head; hold them in this 
position for a few seconds (see Fig. 5). This motion expands the 
chest. Now slowly bring the arms down along the sides and front of 
the chest, squeezing the air out of the chest in so doing (Fig. 6). 




Fig. 5. — Sylvester's Method of Artificial Respiration. First Motion (Inspira- 
tion). (After Doty's "Prompt Aid to the Injured.") 

Each movement should be done from twelve to sixteen times a 
minute. When an assistant is present he should make a strong up- 
ward pressure on the sides of the ribs and stomach, as the arms are 
being brought down to expel the air from the chest (see Fig. 7), and 
after a few seconds the assistant suddenly lifts his hands from 
the body, when the operator will again lift the patient's arms over 
his head. This method is more effective than can be done by one 
man alone. This artificial breathing should be continued for four 
hours if necessary, as persons have been revived who showed no 
signs of so doing until after two hours. Breathing begins in short 
gasps. Individuals have also been submerged under water for nearly 
an hour and yet have been resuscitated. If there are other assist- 
ants they should place hot water bags at the feet, being careful 
not to burn the patient, and dry and rub the limbs and belly and 
cover him warmly, but not so as to interfere with the artificial 
breathing operations. 



38 DROWNING— ELECTRIC SHOCK— POISONING BY GASES 

When breathing has become normal cover the patient warmly 
from head to foot and give a little hot coffee or a tablespoonful of 
whisky or brandy in hot water every fifteen minutes, for the first 
hour, and afterwards as may seem necessary. The patient should 
keep perfectly quiet in bed for forty-eight hours, or he may be seized 
with congestion of the lungs. If this occurs there is great diffi- 
culty in breathing and if the patient gasps for breath artificial breath- 
ing may have to be instigated again. 




Fig. 6. — Sylvester's Method of Artificial Respiration. Second Motion (Expira- 
tion). (After Doty's "Prompt Aid to the Injured.") 

The application of a large mustard poultice (one part of mus- 
tard and two parts of flour, mixed in a paste with warm water and 
spread between two old pieces of cotton) applied over the front of 
the chest, will often give immediate relief. 



RESCUING A DROWNING PERSON BY SWIMMING 

Before jumping into the water to rescue a drowning person 
throw off your coat and vest — and if there is time — your shoes, 
trousers, and drawers. The weight of the outer clothing, after it 
is completely water-soaked, is much greater than would be imagined. 
Cry out to the drowning person that he is safe. When you get 
close to the struggling person wait till he is pretty well used up 
and quiet before trying to aid him, or he will drown you. The 
writer has saved a person from drowning by waiting until the 
subject was quite unconscious and then seizing the hair with one 
hand while swimming on the back and side with the other. 

By grasping the subject with one or both hands and swinging him 



ELECTRIC SHOOK 39 

on his back, one can readily swim on one's own back with the 
feet alone, or float when tired. The only safe way then to at- 
tempt a rescue is: Grasp the hair, throw the subject on his back, 
and swim on one's own back. Do not touch the victim while he is 
violent and struggling. Take your time and wait for a boat, if one 
is at hand, and do not necessarily try to land the patient. 

In diving for a person below the surface be guided by rising 
bubbles of air. 

ELECTRIC SHOCK 

Lightning stroke is rare: statistics show that there is but one 
death in a million annually from this cause in the United States. 

Electric shock from the commercial currents is a comparatively 
common occurrence. The cause of death is failure of the heart 
or of breathing. If the heart fails there is no practical way at 
present to restore it, but the breathing may be restored if the pa- 
tient does not stop breathing over four or five minutes before res- 
piration is artificially begun. 

Different kinds of currents have different effects on the body. 
Thus the direct currents of high voltage tend to arrest the 
heart, while they affect the nervous system to cause unconsciousness, 
as by ether, and operations have been done without pain or con- 
sciousness under electricity given to animals. In the case of the 
alternating currents of high voltage the breathing is most apt to be 
arrested, while with currents of large amperage of low tension 
death from heart failure is most common. 

The nervous system is the chief sufferer from currents of over 
4,500 volts. But of even more consequence is the area, duration, 
and location of points of contact of current, and the resistance 
offered by dry clothing and skin to the penetration of the elec- 
tricity. A dog may be killed by a current of 10 volts when the 
contacts are made to the head and hind legs, because the current 
then flows through the heart. A current of 80 volts is required of 
the same amperage, if contacts are made to the head and foreleg. 
Alternating currents of low frequency are most injurious and any 



40 DROWNING— ELECTRIC SHOCK— POISONING BY GASES 

current tension higher than 200 volts is dangerous to life. A cur- 
rent of 95 volts has proved fatal to a man standing on an iron 
tank in wet boots. On the other hand, in one of the earlier attempts 
at electrocution, a man received a current of 1,700 volts (periodicity 
about 130) for 50 seconds and lived. A strong physique is most 
favorable for resisting the action of electricity. High tension al- 
ternating currents (1,300 to 2,000) are employed in electrocu- 
tions with contacts made to the head and leg, so that the current 
passes through the brain and heart. In industrial accidents such 
nice adjustments are fortunately almost impossible and shocks 
received from currents of 25,000 volts have not proved fatal because 
both voltage and amperage have been greatly lessened through poor 
contacts and resistance of dry clothing and skin, and because the 
heart has not been included in the circuit. 

Death is induced in one of three ways : ( 1 ) currents of enormous 
voltage and amperage, as occur in lightning, actually destroy, burst, 
and burn the tissues through which the stroke passes; (2) death 
from contraction of the muscles of the heart, the effect being much 
the same as that observed in other muscles. The heart instantly 
stops beating in a state of contraction, or there is a fine quivering 
of the muscular fibers, but the normal pulsations are not resumed; 
(3) the effects of the current on the nerve centers in the brain may 
arrest breathing. 

Most of the industrial currents are alternating, of varying fre- 
quency and of high voltage and large amperage and, according to 
the foregoing, cause death by failure of respiration. 

Symptoms. — These are usually general muscular contractions or, 
if the current has passed through the head, sometimes convulsions 
and unconsciousness with failure of pulse and breathing. Uncon- 
sciousness often lasts but a few moments in non-fatal cases, but 
may continue for hours, and is not at all unfavorable if the pulse 
and breathing are satisfactory. Bad after-effects are rare. Occa- 
sionally there is temporary, muscular weakness. A man who was 
removing a brush from a trolley car touched, with the other hand, 
a live rail; his muscles immediately contracted and threw him 
from contact with the current (500 volts). He fainted, the breath- 



ELECTRIC SHOCK 41 

ing was feeble and rapid but later slow, the pulse was rapid and 
weak; on regaining consciousness, he vomited and was on his feet, 
although he was feeling very weak for two hours. This is a mild 
case. 

Burns of varying degrees of intensity occur at the point of en- 
trance of the current, from slight blisters to complete destruction 
of all the tissues at this point. The treatment is the same as for 
burns in general. 

Treatment. — Artificial respiration should always be kept up until 
a medical man takes care of the case, as the layman cannot surely 
know whether or not the patient is dead, and patients have been 
restored after two hours of artificial respiration. 

1. BREAK THE CIRCUIT IMMEDIATELY 

(1) With a single quick motion separate the victim from the 
live conductor — in so doing avoid receiving a shock yourself. Many 
have, by their carelessness, received injury in trying to disconnect 
victims of shock from live conductors. Observe the following pre- 
cautions : — 

(a) Use a dry coat, a dry rope, a dry stick or board, or any 
other dry nonconductor, to move either the victim or the wire, so 
as to break the electrical contact. Beware of using metal or any 
moist material. The victim's loose clothing, if dry, may be used to 
pull him away; do not touch the soles or heels of his shoes while 
he remains in contact — the nails are dangerous. 

(b) If the body must be touched with your hands, be sure to 
cover them with rubber gloves, mackintosh, rubber sheeting or dry 
cloth; or stand on a dry board or some other dry insulating sub- 
stance. If possible, use only one hand. If the victim is conducting 
the current to ground, and is convulsively clutching the live con- 
ductor, it may be easier to shut off the current by lifting him than 
by leaving him on the ground and trying to break his grasp. 

(2) Open the nearest switch, if that is the quickest way to 
break the circuit. 

(3) If necessary cut a live wire; use an ax or hatchet with a 
dry wooden handle, or properly insulated pliers. 



42 DROWNING— ELECTRIC SHOCK— POISONING BY GASES 

2. ATTEND INSTANTLY TO THE VICTIM'S BREATHING 

(1) As soon as the victim is clear of the live conductor, quickly 
feel with your finger in his mouth or throat and remove any foreign 
body (tobacco, false teeth, etc.). Then begin artificial respiration 
at once; every moment of delay is serious. 

(2) Lay the subject on his back with a large roll of clothing 
under his shoulders and with arms stretched as straight forward 
as possible and the wrists fastened together. Let an assistant draw 
forward the subject's tongue. If possible, avoid so laying the 




Fig. 7. 



-Artificial Respiration. Howard's Method. (After Doty's "Prompt Aid 
to the Injured.") 



subject that any burned places are pressed upon. Do not permit 
bystanders to crowd about and shut off the air. 

(3) Kneel, straddling the subject's thighs and facing his head; 
rest the palms of your hands on the muscles of the sides of the 
chest, with thumbs nearly touching each other, and with fingers 
spread over the lowest ribs (see Fig. 7). 

(4) With arms held straight, swing slowly forward so that 
the weight of your body is gradually brought to bear on the sub- 
ject. This operation, which should take from two to three seconds, 
must not be violent — internal organs might be injured. The lower 
part of the chest and also the ai)domen are thus compressed, and 
air is forced out of the lungs. 

(5) Now immediately swing backward so as to remove the pres- 
sure, but leave your hands in place, thus returning to the first posi- 
tion. Through their elasticity, the chest walls expand and the lungs 
are thus supplied with fresh air. 



POISONING BY GASES 43 

(6) After two seconds, swing forward again. Thus repeat de- 
liberately twelve to fifteen times the double movement of com- 
pression and release — a complete respiration in four or five seconds. 
If a watch or clock is not visible, follow the natural rate of your 
own deep breathing, swinging forward with each expiration and 
backward with each inspiration. While this is being done, an as- 
sistant should loosen any tight clothing about the subject's neck, 
chest, or waist. 

(7) Continue artificial respiration for two hours or longer, 
without interruption, until natural breathing is restored or until a 
physician arrives. Even after natural breathing begins, carefully 
watch that it continues ; if it stops, start artificial respiration again. 
During the period of operation, keep the subject warm by applying 
a proper covering and by laying beside his body bottles or rubber 
bags filled with warm (not hot) water. The attention to keeping 
the subject warm should be given by an assistant or assistants. 

(8) Do not give any liquid by the mouth until the subject is 
fully conscious. 1 

POISONING BY GASES 

In rescuing a person from a room filled with gas or smoke one 
should cover his nose and mouth with a cloth wet with water or 
vinegar and, taking a full breath, should rush for the nearest win- 
dow and open or break it to get a sufficient supply of air. The 
other windows and doors should then be opened. Xever take a 
light or strike a match in a room full of gas — in this way an ex- 
plosion will be avoided. Remove the patient at once to a pure 
atmosphere and try to revive him by artificial breathing, as de- 
scribed elsewhere in this volume. The machine called the pulmotor, 
or lung motor, which automatically sustains breathing, is of great 
value and more efficient than any other means. It is now a part of 
the necessary appliances kept on hand by city hospitals, fire houses 
and others called upon to treat medical and surgical emergencies. 

1 Rules of the Commission on Resuscitation from Electric Shock of the 
National Electric Light Association. The method of performing artificial respira- 
tion is Howard's, and not that described by the Association. 



44 DROWNING— ELECTRIC SHOCK— POISONING BY GASES 

Suffocation in houses is apt to occur from escaping illuminating 
gas and also from charcoal and coal gas. The treatment of those 
suffocated by gas in mines, wells, and sewers is precisely the same 
as that described above. 



CHAPTEE III 
UNCONSCIOUSNESS AND CONVULSIONS 

Heat prostration. Heat stroke. Fainting. Intoxication. Head injuries. 
Apoplexy. Kidney disease. Epilepsy. Hysteria. Diabetes. Shock. 
Poisoning by opium, carbolic acid, and strychnin. Convulsions in in- 
fants and adults. 

General Treatment. — The patient's head should be moved as 
little and as carefully as possible. He should be put to bed or flat 
on his back, or if the breathing is of a snoring, noisy, or rattling 
character, turn the patient carefully on his side so that the tongue 
will not fall back. Loosen the clothing about the neck and body, 
and replace it with night clothes if possible. Do not try to make 
the patient swallow anything until consciousness has returned, or 
it may choke him, or go down into the lungs. Mistaken kindness 
frequently results in attempts to pour whisky down the throat of 
an unconscious person. 

If there is an injury to the head or the face is red, put ice to 
the bead in a rubber bag, sponge bag, or towel, and keep the feet 
warm with hot water bags or bottles. 

Give the patient plenty of air and do not let bystanders crowd 
about him. 

Causes. — In adults brain injuries or disease, acute diseases, 
poisons, and heart disease are the most common causes of uncon- 
sciousness. Among diseases of the brain, apoplexy, epilepsy, sun- 
stroke, and meningitis are common. Among poisons alcohol, chloral, 
opium, illuminating gas, and the poisons produced by Bright's 
disease and diabetes are frequent causes of unconsciousness. Sim- 
ple fainting is the most common cause of short insensibility, but 
organic disease of the heart may also be present. Hysteria 

45 



46 UNCONSCIOUSNESS AND CONVULSIONS 

may be a cause, especially in women, and convulsions in chil- 
dren. Convulsions or fits may be feigned to obtain money or drink. 

Get all the information possible from bystanders as to whether 
there has been any injury or previous sickness. Examine the head 
and body for broken bones. Take the temperature by placing a 
thermometer in the bowel, if possible. A temperature over 100° F. 
may mean acute disease, such as typhoid fever, pneumonia, menin- 
gitis, sunstroke. A pulse of 60 or under suggests brain injury or 
disease. 

Consider the color of the face : if it is flushed and bluish it may 
mean apoplexy or epilepsy; if pale it may mean fainting or shock 
from injury. Has the patient bitten his tongue ? If so, there is 
a probability of a previous epileptic fit. The odor of alcohol in 
the breath does not necessarily mean drunkenness. Find out how 
much alcohol the patient has had and examine into the other points 
mentioned. Examine the mouth. The swallowing of carbolic acid 
turns the lips and tongue whitish. 

Is there any swelling about the ankles so that the finger tip 
pressed firmly on the flesh covering the shin bone above the ankles 
leaves deep imprints ? This, with a previous history of vomiting, 
suggests Bright's disease of the kidney as the cause. 

Touching the central part of the eyeball lightly with the finger 
tip will show the depth of unconsciousness. If the patient is but 
partly unconscious he will try to wink and frown, but if wholly 
insensible he will make no motion. In unconsciousness due to 
apoplexy there is paralysis of one whole side of the body; lift the 
two legs and let them fall and see if one side appears to be lifeless 
as compared to the other. 

Unconsciousness is often associated with convulsions. Inquire 
if there have been convulsions as they always occur in epilepsy, 
and the tongue has often been bitten. Fits are also seen in head in- 
juries and diease, in strychnin poisoning, in Bright's disease, occa- 
sionally in fainting, and often in hysteria, and in fevers and diges- 
tive diseases of infants. The patient may apparently be wholly 
unconscious in hysteria and insensible to pain, noise and light : this 
is not the case, however, for dashing cold water on the face will 



SUNSTROKE 47 

often cause struggling; or covering the nose and mouth may lead 
to resistance; and trembling of the eyelids and rolling up of the 
eyeballs are common in hysteria. The patient is often very stiff 
and bends backward. There may be confused talk or screaming. 
Hysteria occurs more often in women and after some emotional 
excitement. 

SUNSTROKE 

HEAT PROSTRATION— HEAT STROKE 

There are two very distinct types of sickness from heat com- 
monly included under the name of sunstroke. Either may occur 
in persons exposed directly to the sun's rays or in those exposed to 
great heat out of the rays of the sun. Heat stroke is seen more often 
in persons working out in the sun, however. 

Heat Prostration 

In this condition there is f aintness and great weakness ; the face 
is cool and pale; nausea, vomiting, and dizziness may be present 
and sometimes actual unconsciousness. There is no fever, the tem- 
perature is normal or below. 

Treatment. — Assist the patient to lie flat on his back, and loosen 
the clothing about the neck and waist. Lift the foot of the bed 
two feet higher than the head. Give plenty of air. Sprinkle ice 
water on the face and hold smelling salts to the nose. When the 
patient can swallow give a tablespoonful of whisky or brandy in 
a little water, or one-half teaspoonful of aromatic spirit of am- 
monia in one-half a cup of water. Make the patient lie quietly 
for some time after the faintness has passed. 

Heat Stroke 

In this condition there are flushed face, hot skin, high fever (the 
thermometer in the bowel may show 107° to 110° F.), and rapid 
and complete unconsciousness with noisy breathing. It may appear 
suddenly with nausea, dizziness, headache, and the patient may fall 



48 UNCONSCIOUSNESS AXD CONVULSIONS 

insensible to the ground. The muscles are usually relaxed, but some- 
times there are twitchings or even convulsions. 

In comparing the two forms it will be seen that in heat prostra- 
tion we have a condition of faintness, while in heat stroke there 
is a state with hot skin, red face, and insensibility, which looks 
more like intoxication or apoplexy. The thermometer settles the 
diagnosis. 

Heat prostration is frequently seen in those working in hot rooms, 
as laundries, boiler rooms, and stoke holes. It occurs more often 
in those weakened by overwork, poor food and excesses in alcohol. 
It is not infrequent in children. It is seen more commonly in men 
wearing thick clothing, working in great heat, and exposed to the 
sun, and especially in those under the influence of alcohol. Heat 
prostration with proper care, usually is of short duration. In heat 
stroke delirium and unconsciousness may last for days. Diminution 
of fever and returning consciousness herald recovery,' but it is a 
very fatal disease — more than a third of the cases dying. In fatal 
cases the pulse weakens, the insensibility is profound, and the breath- 
ing is gasping, with long intervals. When the patient survives there 
is commonly great sensitiveness to moderate heat for many years 
after. Loss of memory, weakened mental capacity, headache, irri- 
tability, impairment of sight and hearing are all seen as sequels, 
particularly in those who drink or are exposed to hot weather. 
Cramps in the muscles are frequent in those working about fur- 
naces in hot rooms. Sunstroke is more common in a sultry moist 
atmosphere than in places possessing dry air, but higher temperature. 

There is no explanation for the greater frequency of the disease 
in some regions as compared with others having apparently the 
same general atmospheric conditions. 

Treatment. — Ice wrapped in a towel should at once be applied 
to the head. The patient must be stripped of clothing and placed 
in a bath tub containing ice water, and should be rubbed all over 
with ice, keeping ice on the head; or he may be placed in a cot 
and wrapped in a sheet wrung out of ice water and the outside 
of the sheet rubbed with ice. A lump of ice should be kept 
at the nape of the neck. This rubbing of the body with ice is 



FAINTING 49 

essential whether the patient be in a bath or covered by a sheet. 
The friction stimulates the nervous system and circulation and 
thus prevents the blood from being driven into the internal organs 
by the cold applied externally. The cold water treatment is applied 
until the temperature of the patient has been reduced to normal 
(98.6° F.), or within a few degrees of it. Then the patient is put 
to bed with an icecap on his head and kept there until he recovers. 
It often happens that fever returns, in which case the whole process 
of applying cold w T ater must be repeated. While the patient is 
insensible no attempt should be made to give him anything by the 
mouth, but one-half pint of milk containing two raw eggs and a 
large pinch of salt may be w T armed to the body temperature and 
injected into the bowel every eight hours, after washing the bowel 
out with cold water on each occasion. 

If the pulse is weak four tablespoonfuls of whisky or brandy 
may be added to the milk. If the urine is not passed spontaneously 
it will be necessary to draw it once in every eight hours with a 
soft rubber catheter which has been boiled for ten minutes and 
lubricated with glycerin, the hands of the operator being scrupu- 
lously clean. 

It goes without saying that a physician's services are imperative 
in any form of sunstroke. 

FAINTING 

{Syncope) 

Fainting is the most frequent cause of unconsciousness. It is 
a condition of temporary insensibility due to insufficient blood supply 
to the brain. This is brought about through weakness of the blood 
vessels, so that the blood is not distributed uniformly about the 
body, or through weak action of the heart caused by general ex- 
haustion or weakness, pain, fright, excitement, nervousness, and 
anemia. Great loss of blood w r ill of course produce fainting. Cer- 
tain odors and sights produce fainting, even in robust persons, as 
the sight of blood or surgical operation. Fainting is apt to be a 
habit in some persons, more often in women. It is more prone 



50 UNCONSCIOUSNESS AND CONVULSIONS 

to occur at gatherings where the air is warm and close. The blood 
vessels then are relaxed and the blood withdrawn from the head. At 
the first feeling of faintness one may avoid fainting by stooping 
down, with the head below the knees. 

Most cases of fainting are not dependent upon real heart disease, 
and it is not usually a serious matter, except in persons over fifty 
when it often means disease of the heart, brain or kidneys. 

Symptoms. — In fainting the patient often feels dizzy and weak 
and becomes very pale. If insensibility is complete he falls and 
the breathing and heart apparently may stop or be so feeble that 
neither the respiration nor pulse are perceptible. This is but mo- 
mentary, hpwever. Rarely there are slight convulsive movements 
so that the patient may appear to be in a fit. 

Treatment. — The first thing to do is to lay the patient flat on 
his back, and raise his legs higher than his head so that the blood 
will flow into his brain; there should be no pillow under the head. 

The clothing should be loosened about his neck and body, and 
cool air should be let into the room to stimulate contraction of 
the blood vessels. Sprinkling cold water on the face and the ap- 
plication of smelling salts, or inhalation of ammonia from a bottle, 
are useful. The patient should not be given anything by the mouth 
until able to swallow, and then a tablespoonful of whisky or brandy 
in a little water may be reviving. 

The patient must remain on his back for some time after re- 
covering from the attack. 



INTOXICATION 

Unconsciousness from other conditions is frequently set down to 
drunkenness when the odor of alcohol is present in the breath. The 
patient may have fallen and fractured his skull when drunk, or 
have an attack of apoplexy due to drink. He may not be drunk 
at all, but may simply have had a drink, or been given one for 
injury or disease. In drunkenness there may be a history of drink- 
ing and an alcoholic breath. 



HEAD INJURIES 51 

Symptoms. — The patient can generally be aroused by shouting 
or shaking and will make some muttering reply which is not so 
apt to occur in apoplexy or fractured skull. The face is flushed, 
and the breathing deep, but not so noisy and snoring, as in apo- 
plexy. The pulse in intoxication is rapid and not so slow (60 or 
below) as in opium poisoning, and often in apoplexy and injuries 
and diseases of the brain. 

Treatment. — Ordinary intoxication will pass off without any 
treatment but sleep and rest. 

If the pulse is weak one-half teaspoonful of aromatic spirit of 
ammonia in one-half glass of water will aid recovery. If the stupor 
is profound arouse the patient by giving douches of cold water 
on his head and striking his bare skin with a wet towel. Then give 
a dessertspoonful of mustard, with a teaspoonful of common salt, 
in a glass of tepid water to empty the stomach. After that give 
three compound cathartic pills to move the bowels and put the 
patient to bed. If the pulse is weak repeat the ammonia and give 
strong coffee. 

HEAD INJURIES 

CONCUSSION 

The simplest form of unconsciousness from a fall or blow on 
the head is that due to concussion or jarring of the brain. 

Symptoms. — Here the insensibility may be short, the patient 
may be pallid, weak and confused, and have nausea or vomiting on 
recovery. 

In the severer forms the patient is unconscious but may reply 
in monosyllables to shouting. If the patient moves all his limbs 
there is no paralysis; the latter may occur in severe head injuries. 
Occasionally there are convulsions. Recovery of consciousness in 
severe concussion of the brain usually ensues within twenty-four 
hours, but headache, dizziness, and incapacity for mental work may 
persist for a considerable time. 

There is a possibility for brain abscess, inflammation, epilepsy, 
or relapse into unconsciousness after a time, if the patient does 
not rest. 



52 UNCONSCIOUSNESS AND CONVULSIONS 

Treatment. — The general treatment for unconsciousness de- 
scribed above is advisable, with icebags or cold cloths to the head 
and hot water bags at the feet, and prolonged rest in bed. The 
patient should live a quiet life for some time, not returning to 
business for several weeks. 

COMPRESSION OF THE BRAIN 

Symptoms. — In the more severe head injuries, known as com- 
pression of the brain, from the escape of blood and formation of 
clots between the brain and skull, or from breaking or fracture 
of the bones of the skull, with pressure on the brain, there are: 
complete unconsciousness, so that the patient will not respond to 
any effort to arouse him, snoring breathing, slow pulse, and wide 
or unequal pupils, which do not contract when exposed to a bright 
light. There is often paralysis of one side of the body. 

FRACTURE OF THE SKULL 

Symptoms. — In fracture of the skull there may be no external 
sign, although there may be a depression in the skull, or the broken 
bones may be felt grating together when the parts are pressed upon. 
A continuous flow of bloody or watery fluid from the ear is usually 
a sign of fracture of the skull after injury, and also the appear- 
ance of blood staining the white of the eye or lid, a day or two 
after the accident. 

Treatment. — A surgeon should be summoned at any cost in a 
case of delayed unconsciousness. When there exists any possibility 
of a head injury in an unconscious person the entire head should 
be shaved, as only then may swelling or abrasions be seen. 

The treatment is the same as that recommended for concussion 
until skilled assistance is obtained. 



APOPLEXY 

This is a form of unconsciousness due to pressure of a blood 
clot on the brain resulting from the spontaneous rupture of a blood 
vessel. It is more likely to attack men over fifty years of age. 



KIDNEY DISEASE 53 

Symptoms. — The face is flushed and of a bluish hue. The breath- 
ing is often loud, rattling and of a snoring character, and may be 
irregular. The cheeks flap in and out, and the lips sputter. The 
patient moves the arm and leg on one side of the body while the 
other side lies motionless and is paralyzed. The face may be para- 
lyzed on one side, the lips being puffed out on that side in breathing. 
There is usually complete insensibility so that the patient cannot 
be roused. The pupils of the eyes are not equal in size. The 
limbs are entirely relaxed or stiff on the paralyzed side of the 
body, and the face is often turned to the sound side. 

While the person with apoplexy may also be under the influence 
of alcohol, yet apoplexy may be distinguished from intoxication by 
the facts that in intoxication the patient can be temporarily roused 
by shouting, and there is no paralysis on one side of the body, and 
the pupils are equal in size. 

Treatment. — The patient should be placed on his back with his 
head raised, or turned on his side if his breathing is very noisy. 
Cold cloths or ice should be placed at his head and hot water bags 
at his feet. 

Do not try to give food or drink, especially alcohol, while the 
patient is unconscious. Five grains of calomel may be dropped 
on the back of the tongue, however. And the urine may have to 
be drawn off with a catheter every eight hours. After a variable 
time, "from a few hours to many days, the patient may return to 
consciousness — usually to suffer from paralysis for a longer or 
shorter period. Death may occur while the patient is still un- 
conscious. 

Patients who are in bed for long periods, with paralysis, must 
be kept very clean, and turned from time to time to avoid bed- 
sores from pressure in the lower part of the back. Bathe ,such 
parts frequently with alcohol and water and see that the bed cloth- 
ing under the patient is not wrinkled. 

KIDNEY DISEASE 

This condition may be a cause of unconsciousness, called uremia. 
It is due to the retention of certain poisonous matters which should 



5-i UNCONSCIOUSNESS AND CONVULSIONS 

be eliminated from the body in the urine. A previous history of 
vomiting, headache, dizziness and sleeplessness may be obtained, and 
the face of the patient may be pale and bloated, with swelling of 
the eyelids and ankles from dropsy. The breath and skin may 
have an odor of urine. The unconsciousness is often preceded by 
convulsions. 

It is, however, usually impossible for the layman to make a cor- 
rect diagnosis of the condition. 



EPILEPSY 

The unconsciousness begins with a fit. The tongue may be 
bitten; there may be a history of such attacks, and the patient 
usually regains consciousness in a short time, although occasionally 
there is a prolonged period of insensibility. 



HYSTERIA 

Apparent insensibility and convulsions are seen in hysteria. 
This is a nervous disease, in which the emotions control the body, 
more often attacking young women. 

Symptoms. — The patient, owing to some emotional excitement, 
begins by alternately crying and laughing and has a sensation as 
of a lump in the throat and of choking and difficulty in getting 
breath. She then often falls, apparently unconscious and in con- 
vulsions. In falling the patient usually manages not to hurt herself 
and rarely bites the tongue, as in epilepsy. The arms, legs and 
head are thrown about in a wild manner. After a few minutes 
the attack may cease and the patient begins crying again and may 
regain consciousness. Often the patient may remain for a long 
time in an apparently unconscious condition, with little movement 
of the body which may assume various postures and be held per- 
fectly rigid. The history of similar attacks beginning with weep- 
ing and laughing, the feeling of a lump in the throat, and the fact 
that the patient has never been hurt in the convulsions, as occurs 



SURGICAL SHOCK 55 

in epilepsy, will suggest hysteria very strongly. Covering the nose 
and mouth may cause resistance, and rolling up of the eyeballs and 
trembling of the eyelids are common in hysteria. 

Treatment.— Hysteria must be regarded as a disease and the pa- 
tient should not be treated unkindly; but on the other hand sym- 
pathy may aggravate the condition. While the patient may be 
apparently unconscious she can hear what is said. It is well then 
in a loud voice to tell some one in the room that the patient is in 
no danger and that the attack will pass soon. This naturally comes 
with more authority from a doctor. 

The patient should then be left alone in a darkened room, or, 
if the attack is severe, the sudden dashing of a large pitcherful of 
cold water on the face and head of the patient will usually quickly 
restore her. 

Hysteria may stimulate almost any other disease and its vaga- 
ries are myriad. Only the form is here considered in which con- 
vulsions and insensibility predominate. 



DIABETES 

A large number of patients with diabetes die in unconsciousness 
or coma. The breath has a fruity, sweet odor likened to that of 
apples or pears, or to wine. There are no previous convulsions, 
but the patient may have had headache, dizziness, and a staggering 
gait. One may find that the patient has been previously treated 
for diabetes. The finding of sugar in the urine is not positive proof 
of the condition. 

SURGICAL SHOCK 

This is a condition in which there may be partial unconscious- 
ness. Shock is profound depression of the nerve centers, particu- 
larly those controlling the blood vessels. With this control lost 
the great veins in the abdomen dilate, thus collecting most of the 
blood in the body; in consequence the heart and brain suffer from 
loss of blood supply. Shock is commonly produced by injuries as 



56 UNCONSCIOUSNESS AND CONVULSIONS 

by falls, blows, wounds, fractures, surgery, shooting, burns ; and also 
by great fear or grief, loss of blood, and exposure to cold. 

If nerves leading from the seat of injury to the brain are tem- 
porarily disabled by injection of cocain, shock may be prevented. 

This is now done in surgery. Shock may come on suddenly, 
or after hours, as following railroad accidents. It may be slight 
and short, or severe and prolonged, or death may occur suddenly 
from shock. 

Symptoms. — A patient with shock will lie quiet, pale, limp and 
indifferent, with partially closed eyes. The skin is pale, cold and 
clammy. The breathing is faint or gasping, the pulse feeble and 
rapid or imperceptible, the pupils are dilated, and the temperature 
below normal. The patient may answer questions, but his replies 
are usually wholly unreliable then and later concerning that period. 
Pain is not felt. 

Vomiting may herald reaction with beginning recovery. The 
color grows better, the skin warmer, and the breathing and pulse 
become stronger. 

Treatment.— The head should be lowered by lifting the foot of 
the bed on a chair or on boxes. Hot water bags should be placed 
about the patient, being careful not to burn him. He should be 
warmly covered with blankets and the lower limbs bandaged from 
toes to groin. 

The slow injection into the bowel of two quarts of water (as 
hot as the hand can comfortably bear) containing four level tea- 
spoonfuls of salt and one-half cupful of brandy or whisky is of 
great value, except in shock from loss of blood. The water should 
flow from a fountain syringe hung about a foot above the patient, 
and the patient must be kept covered while the injection is given. 
Mustard plasters should be placed over the heart and spine. 

Giving stimulant by the mouth in shock is useless. Even in- 
jecting ordinary agents, as alcohol and strychnin, under the skin 
does little good — the injection by a doctor of one-quarter of one 
grain of morphin sulphate, and of one one-hundredth of one grain 
of atropin sulphate, are of service. If a surgeon can inject adren- 
alin chlorid solution into an artery this will accomplish most. 



CONVULSIONS 57 

Performing artificial breathing by alternating pressure on the sides 
of the lower part of the chest may be of value. When the patient 
improves hot coffee may be given by the mouth. 



POISONING 

Unconsciousness may be due to poisoning by many chemicals. 
Poisoning by alcohol, gases and the special poisons of Bright's disease 
and diabetes have been mentioned. Poisoning by opium or morphin, 
carbolic acid, and strychnin will produce unconsciousness. 

In opium poisoning the patient can usually be aroused some- 
what by shaking and shouting; the breathing and pulse are very 
slow and the pupils of the eyes are reduced to pin points. 

In carbolic acid poisoning there are white marks on the lips 
from burning, and the odor of the acid is perceived. 

In strychnin poisoning there are convulsions also, when the 
patient is so bent and rigid that he will rest on his head and heels. 



CONVULSIONS 

CONVULSIONS IN CHILDREN 

Treatment. — Hold the child in a warm bath with a cold cloth 
on the head; repeat the same treatment if the convulsions return. 
Send for a doctor. 

CONVULSIONS IN ADULTS 

(Fits) 

Treatment. — Loosen the clothing about the waist and neck. Place 
a cork or bit of wood between the teeth to prevent biting of the 
tongue. Keep the patient from falling off the bed or better lay 
the patient on the floor. Crush a pearl of amyl nitrite (kept by 
druggists) on a handkerchief and hold this close to the patient's 
nose and mouth until he becomes relaxed. Do not try to rouse 
the patient from his sleep after his fit has passed. 

Cause.- — The most common cause of such fits is epilepsy. 



CHAPTEE IV 
FKACTUKES OK BKOKEN BONES * 

Broken rib. Collar bone. Lower jaw. Nose. Shoulder blade. Arm. Fore- 
arm. Wrist. Hand. Fingers. Hip. Thigh. Kneepan. Leg. Ankle. 
Foot. Toes. Compound fractures. 

It frequently happens that the first treatment of fracture de- 
volves upon the inexperienced layman. Immediate treatment is not 
essential, in so far as the repair of the fracture is directly con- 
cerned, for a broken bone does not begin to unite for a week or 
so, and if a fracture were not seen by the surgeon for several days 
after its occurrence, no harm would be done provided that the limb 
were kept quiet in fair position until that time. The object of 
immediate care of a simple fracture is to prevent pain and avoid 
damage which would ensue if the sharp ends of the broken bone 
were allowed to injure the soft tissues during movements of the 
broken limb. 

When Immediate Treatment is Necessary. — The foregoing re- 
marks apply to simple fractures but when there is a wound near 
the seat of fracture, or when the ends of the broken bones actually 
project through the skin, then immediate treatment is essential to 
save the patient's limb or life (see Compound Fracture). 

Fractures are partial or complete, the former when the bone is 

broken only part way through; simple, when the fracture is a 

break of the bone, and compound, when there is an external wound 

communicating with the seat of fracture and allowing the air with 

its germs to enter the wound, thus greatly increasing the danger. 

x It should be distinctly understood that the information about fractures is 
not supplied to enable anyone to avoid calling a surgeon; it is to be followed 
only until expert assistance can be obtained and. like other advice in this book, 
is intended to furnish first-aid information or directions to those who are in 
places where physicians cannot be secured. 

58 



SPECIAL FRACTURES 59 

Causes.' — To be sure that a bone is broken we must consider sev- 
eral points. The patient has usually fallen or has received a severe 
blow upon the part. This is not necessarily true, for old people 
often break the thigh bone at the hip joint by simply making a false 
step. 

Symptoms. — Inability to use the limb and pain first call our 
attention to a broken bone. Then when we examine the seat of 
injury we usually notice some deformity — the limb or bone is out 
of line, and there may be an unusual swelling. But to distinguish 
this condition from sprain or bruise, we must find that there is a 
new joint in the course of the bone where there ought not to be 
any: e. g., if the leg were broken midway between the knee and 
ankle, we should feel that there was apparently a new joint at this 
place, and perhaps the ends of the fragments of bones would be 
heard or felt grating together. 

Tests.- — These, then, are the absolute tests of a broken bone: — 
movement in an unusual site in the course of the bone, and grating 
of the broken fragments together. The latter will not occur, of 
course, unless the fragments happen to lie so that the ends touch 
each other. In the case of limbs, sudden shortening of the broken 
member from overlapping of the fragments is a sure sign. 



SPECIAL FRACTURES 

BROKEN RIB 

A rib is usually broken by direct violence, as by falls, blows, 
crushing. 

Symptoms. — The symptoms are pain on taking a deep breath, or 
on coughing, together with the finding of a small, very tender point 
on pressure. This is found by passing the finger tip along each 
rib in turn in the region of the pain. Unusual movement or grating 
may be felt at the place of fracture on deep breathing. The existence 
of a very tender spot on a rib after an injury means a probable 
fracture. Deformity is not usually evident, so that nothing in the 
external appearance may call the attention to fracture. Grating 



60 



FRACTURES OR BROKEN BOXES 



between the fragments may be heard by the patient or by the ex- 
aminer, on placing his ear over the painful spot, and the patient can 
often put his own finger on the exact location of the break. 

Treatment. — When there is doubt whether a rib is broken or not 
the treatment for broken rib should be followed for relief of pain. 
The treatment consists in applying a wide band of surgeon's ad- 
hesive plaster, to be obtained at any ding shop. The band is made 

by overlapping strips, 
three inches wide, till a 
width of nine inches is 
obtained. This is then 
applied by sticking one 
end along the back bone 
and carrying it forward 
around the injured side 
of the chest over the 
breastbone as far as a 
line below the armpit on 
the uninjured side of the 
chest, i. e., three-quarters 
way about the chest (see 
Fig. 8). These three- 
inch strips may be cut 
the right length first and laid together, overlapping about two inches, 
and put on as a whole, or. what is easier, each strip may be put on sep- 
arately, beginning at the spine, four inches below the fracture, and 
continuing to apply the strips, overlapping each other about two 
inches, until the band is made to extend to about four inches above 
the point of fracture — all the strips ending in the line of the armpit 
of the uninjured side. Each strip should be quickly put on, while the 
patient lets out all his breath, as at this time the ends of the bones 
are more nearly together. 

If surgeon's plaster cannot be obtained, a strong unbleached cot- 
ton or flannel bandage, a foot wide, should be placed all around the 
chest and fastened as snugly as possible with safety pins, in order to 
limit the motion of the chest wall. The patient will often be more 




Fig. 8. — Strapping with Adhesive Plaster for 
Broken Rib. 



SPECIAL FRACTURES 



61 



comfortable sitting up, and should take care not to be exposed to 

cold or wet for some weeks, as pleurisy or pneumonia may follow. 

The sharp ends of the broken rib may injure the lung and there 

may then be spitting of blood, and air may escape from the lung 

under the skin, giving one a crackling sensation when the skin is 

touched. In such a case, in the absence of a doctor, the patient 

should be kept in bed and be given a tablespoonful (adult dose) of 

paregoric 1 in water, to prevent coughing and quiet the patient. 

Three weeks are required for firm union to be established in broken 

ribs. 

COLLAR BONE FRACTURE 

Fracture of the collar bone is one of the commonest accidents. 
The bone is usually broken in the middle third. 

Symptoms. — A swelling often appears at this point and on press- 





Fig. 9. — Sling fob Collar 
Bone Fracture. 



Fig. 10. — Sling for Col- 
lar Bone Fracture. 



ing gently on either side of the break it may be possible to feel 
movement of the broken fragments. There is inability to use the 
arm (on the side of the break) and there is pain at the site of the 
break, especially on lifting the arm up and away from the body. 
It will be noticed that the shoulder, on the side of the injury, seems 

1 Paregoric is a powerful drug (opium) and is only sold on a doctor's pre- 
scription. 



62 



FKACTUKES OK BROKEN BONES 



narrower and also lower than its fellow. The head is often bent 
toward the injured side, and the arm of the same side is grasped 
below the elbow by the other hand of the patient and supported, 
as in a sling. 

In examining an apparently broken bone the utmost gentleness 
must be used or serious damage may result. 

Treatment. — The best treatment consists of rest in bed on a hard 
mattress; the patient lying flat on the back with a small pillow 

between the shoulders and 
the forearm of the injured 
side across the chest. This 
is a wearisome process, as 
it takes from two to three 
weeks to secure repair of 
the break; on the other 
hand, if the forearm is car- 
ried in a sling, so as to raise 
and support the shoulder, 
while the patient walks 
about, a serviceable result is 
usually obtained, the only 
drawback being that an un- 
sightly swelling remains at 
the seat of the break. 

To make a sling, a piece 
of strong cotton cloth one yard square should be cut diagonally from 
corner to corner, making two right-angled triangles. Each of these 
will make a properly shaped piece for a sling (see Figs. 9, 10 and 

ii). 

To apply the sling place it in the position seen in Eig. 9, 
carrying the end 2 up in front of the forearm and over the right 
shoulder, while the end 1 is brought over the left shoulder and the 
two ends are tied together behind the neck. Then the end 3 is 
brought over the point of the elbow and pinned, as shown in Fig. 11. 
To fix the arm more firmly to the side it is well to apply a bandage 
snugly around the outside of the right arm and body, as seen in 




Fig. 11. — Treatment of Fracture of the 
Collar Bone. 



SPECIAL FRACTURES G3 

Fig. 11. The dressing is kept in place for from 2 to 3 weeks and 
then the arm should be carried in a sling outside the clothes. 

Fracture of the collar bone happens very often in little chil- 
dren, and is commonly only a partial break or splitting of the bone, 
not extending wholly through the shaft so as to divide it into two 
fragments, but causing little more than bending of the bone (the 
a green stick fracture"). 

A fall from a chair or bed is sufficient to cause the accident. A 
child generally cries out on movement of the arm of the injured 
side, or on being lifted by placing the hands under the armpits 
of the patient. A tender swelling is seen at the point of the injury 
of the collar bone. A broad cotton band, with straps over the shoul- 
ders to keep it up, should encircle the body and upper arm of 
the injured side, and the hand of the same side should be supported 
by a narrow sling fastened above behind the neck. 

LOWER JAW FRACTURE 

Fracture of the lower jaw is caused by a direct blow. It involves 
that part of the jaw occupied by the lower teeth, and is more apt 
to occur in the middle line in front or a short distance to one side 
of this point. The force causing the break usually not only breaks 
the bone, but also tears the gum through into the mouth, making 
a compound fracture. 

Symptoms. — There is immediate swelling of the gum at the 
point of injury, and bleeding. The mouth can be opened with dif- 
ficulty. The patient cannot talk plainly, and saliva and blood often 
drip from the mouth. 

The condition of the teeth is the most important point to ob- 
serve. Owing to displacement of the fragments there is a difference 
in the level of the teeth or line of the teeth, or both, at the place 
where the fracture occurs. Also one or more of the teeth are usually 
loosened at this point. In addition, unusual movement of the frag- 
ments may be detected, as well as a grating sound on manipulation. 

Treatment. — The broken fragments should be pressed into place 
with the fingers, and retained temporarily with a four-tailed bandage 
as shown in Fig. 12. This consists of a piece of unbleached cotton 



64 



FRACTURES OR BROKEX BOXES 



cloth four inches wide and one and one-half yards long. It is torn 
into two tails, leaving a strip (five inches long) in the middle intact. 
The central part of the bandage is placed in front 
and under the chin. The two lower tails are then 
carried up and over the head and there tied; the 
two upper tails are brought behind the neck and 
there tied {see Fig. 13). 

Feeding is done through a glass tube, using 
milk, broths, and thin gruels. A mouthwash 
should be employed four times daily, to keep the 
mouth clean and assist in healing the gum. A 
convenient prepara- 
tion consists of men- 
thol, one-half grain ; 
t h y m o 1 , one-half 
grain ; boric acid, 
twenty grains; wa- 
ter, eight ounces. 

The jaw is kept 
permanently 
in proper position 
by the dental sur- 
geon who fits a rub- 
ber splint over the 
whole set of teeth in 
the lower jaw and 
to a tin splint molded to the outside of the 



Fig. 12.— F o u r - 
tailed Bandage 
for Fracture op 
the Lower Jaw. 




Fig. 13. — Treatment of Fracture 
of the Jaw by Means of a Four- 
tailed Bandage. 



fastens this 
jaw. 



FRACTURE OF THE NOSE 

This' may mean a break of the nasal bones ; these are two in 
number. Together they form the upper half of the nose. Or 
the cartilage which forms the lower half of the nose may be sep- 
arated from the nasal bones. In fractures of much severity the 
cartilage which divides the two nasal chambers inside the nose 
may be broken and variously distorted. 



SPECIAL FRACTURES 



65 



Symptoms. — The nose is commonly bent to one side or flattened 
on the face. The swelling may be so great at first that the deformity 
is obscured and not noticed. By very gentle manipulation it may 
be possible to feel the grating of the broken fragments, if the nasal 
bones are fractured. If the deformity is great there is unques- 
tionably a fracture. 

Treatment. — The restoring of the nose to normal shape is often 
a difficult or impossible task. There are all sorts of ingenious ap- 
pliances for this purpose, none of which is 
wholly satisfactory. 

The services of a surgeon should al- 
ways be obtained, if possible. It will often 
be necessary for him to etherize the patient 
in order to restore the internal anatomy of 
the septum. 

The simplest treatment is that of Davis 
whereby one presses externally the bones 
into place as well as possible and then at- 
tempts to hold them there by a small roll of 
bandage on either side of the nose, secured 
by strips of adhesive plaster as in. Fig. 14. 
The nose should be cleaned inside twice 
daily by the use of the Birmingham douche, or gentle syringing, 
with a Seller's tablet (or as much boric acid as will dissolve) in a 
glass of warm water. If the bleeding is serious it may be neces- 
sary to pack the nose (see Nosebleed). 




Fig. 14. — Fracture of the 
Nose Dressed with 
Two Small Bandages 
and Adhesive Strips. 



SHOULDER-BLADE FRACTURE 

Symptoms. — Fracture of the main body of the shoulder-blade oc 
casions pain, swelling, and tenderness on pressure over the point of 
injury. On manipulating the bone a grating sound may be heard 
and movement between the fragments may be felt. 

Treatment. — The treatment consists in binding the arm to the 
body by encircling the body and arm of the injured side (with 
clothes removed) with a wide bandage extending from shoulder to 
elbow, as for fracture of the arm. This bandage is prevented from 



66 FRACTUKES OE BROKEN BONES 

slipping by straps attached to it back and front and carried over 
each shoulder. Then the forearm is carried in a sling as described 
for broken collar bone. 

If adhesive plaster is obtainable it is well to first support the 
shoulder blade by overlapping strips of adhesive plaster, as recom- 
mended for broken rib. The plaster should begin at the spine and 
cover the whole shoulder blade and also the outer part of the arm 
on the injured side. Then the bandage about the arm and body 
and sling are applied as just advised. 

ARM FRACTURE 

Symptoms. — In fracture of the arm (humerus) between the 
shoulder and elbow, swelling and shortening may give rise to de- 
formity. Pain and abnormal motion are symptoms, while a grat- 
ing sound may be detected, but only the gentlest manipulation of 
the arm for this purpose should be attempted. The surface is 
apt. to become black and blue, owing to rupture of the blood ves- 
sels beneath the skin. Measuring the length of both arms, from 
a fixed bony point on each shoulder to the same bony point on 
the outside of each elbow, will show whether there is shortening of 
the injured arm. 

Treatment.- — The hand and forearm should be bandaged from 
below upward to the elbow. The bone is put in place by grasping* 
the patient's elbow and pulling directly down in line with the arm, 
which is held slightly away from the side of the patient, while 
an assistant steadies and pulls up the shoulder. Then a wedge- 
shaped pad, long enough to reach from the patient's armpit to his 
elbow (made of cotton wadding or blanketing sewed in a cotton 
case) about four inches wide and three inches thick at one end, 
tapering up to a point at the other, is placed against the patient's 
side with the tapering end uppermost in the arnrpit and the thick 
end down. This pad is kept in place by a strip of surgeon's ad- 
hesive plaster, or bandage passing through the small end of the 
wedge, and brought up and fastened over the opposite shoulder. 

While the arm is pulled down from the shoulder, three strips 
of well-padded tin or thin board (such as pictureframe backing 



SPECIAL FRACTURES 



67 



or thin box boards) two inches wide and long enough to reach from 
shoulder to elbow, are laid against the bare skin of the front, out- 
side, and back of the arm, and secured by encircling strips of sur- 
geon's plaster or bandage. The arm is then brought onto the pad 
lying against the side under the armpit, and is held there firmly 
by a wide bandage surrounding the arm and entire chest, and reach- 
ing from the shoulder to elbow. It is prevented from slipping by 
strips of cotton cloth, which are placed over the shoulders and pinned 




Fig. 15. 



Fig. 16. 



Figs. 15 and 16. — Treatment of Fracture of Bone of Arm. In Fig. 15, note Splints 
secured by Adhesive Plaster; also Pad in Armpit. In Fig. 16, see Wide Bandage 
around Body, also Sling. 

behind and before to the top of the bandage. The wrist is then 
supported in a sling, not over two inches wide, with the fore- 
arm carried in a horizontal position across the front of the body. 
Firm union of the broken arm takes place usually in from four 
to six weeks (see Figs. 15 and 16). 

A first-aid dressing for a break in the middle of the bone of 
the arm may be made by placing the splints as just described over 
the clothing of the arm, held in place by strips of adhesive plaster 
or bandages, and slinging the hand, as before. 

A first-aid dressing for a break in the upper part of the bone 



68 FRACTURES OR BROKEN BONES 

may be made by folding a towel for a pad in the armpit, holding 
the arm to the side with a bandage about the arm and body, and 
slinging the hand. 

Fractures of the arm near the shoulder joint are not uncom- 
mon and are often mistaken, even by doctors, for dislocations. 
There is pain and inability to use the arm, often discoloration, but 
there may or may not be unnatural movement and grating of the 
fragments at the point of the break. It is always advisable to 
solve the diagnosis by the x-ray in this and all other fractures. 

FRACTURES OF THE ELBOW 

Fractures into a joint are apt to result in stiffness and use- 
lessness of the joint so that these require surgical aid at the earli- 
est possible moment. A temporary dressing for a break about the 
elbow joint consists of the same advised for treatment of a frac- 
tured collar bone, i. e., a wide sling for the forearm and elbow 
with a bandage holding the arm of the injured side to the body. 
(Fig. 11.) 

FOREARM FRACTURES 

Two bones enter into the structure of the forearm. One or 
both of these may be broken. The fracture may be simple or 
compound, when the soft parts are damaged and the break of the 
bone communicates with the air, the ends of the bone even projecting 
through the skin. 

Symptoms. — In fracture of both bones there is marked de- 
formity, caused by displacement of the broken fragments, and un- 
usual motion may be discovered; a grating sound may also be 
detected, but any but the most gentle manipulation of the arm 
should be avoided. 

When only one bone is broken the signs are not so marked, there 
is little deformity, but inability to use the forearm and, on examina- 
tion, there is usually a very tender point at the seat of the frac- 
ture, and an irregularity of the surface of the bone may be felt 
at this point. If a point of false motion and a grating sound can 
also be elicited, the condition is clear. 

Treatment. — The broken bones are put into their proper place 



SPECIAL FRACTURES 



69 



by the operator, who pulls steadily on the wrist, while an assistant 
grasps the upper part of the forearm and pulls the other way. The 
ends of the fragments are at the same time pressed into place by 
the other hand of the operator, so that the proper straight line of 
the limb is restored. 

After the forearm is set, it should be held steadily in the fol- 
lowing position while the splints are applied. The elbow is bent 
so that the forearm is held hori- 
zontally across the front of the 
chest at right angles with the 
arm, with the hand extended — 
open palm toward the body and 
thumb uppermost. The splints, 
two in number, are made of 
wood about one-quarter of an 
inch thick, and one-quarter inch 
wider than the forearm (thin 
box boards are excellent). They 
should be long enough to reach 
from about two inches below the 
elbow to the root of the fingers. 
They are covered smoothly *with 
cotton wadding, cotton wool, 
folded pillow case or towels, 
and then with a bandage. The 
splints are applied to the fore- 
arm in the positions described, one to the back of the hand and fore- 
arm, and the other to the palm of the hand and front of the fore- 
arm. 

Usually there are spaces in the palm of the hand and front 
of the wrist requiring to be filled with extra padding in addition to 
that on the splint. The splints are bound together and to the fore- 
arm by three strips of surgeon's adhesive plaster or bandage about 
two inches wide. One strip is wound about the upper ends of the 
splints, one is wrapped about them above the wrist, and the third 
surrounds the back of the hand and palm, binding the splints to- 




FlG. 



-Treatment of 
Forearm. 



70 FRACTURES OR BROKEX BOXES 

gether below the thumb. The splints should be held firmly in place, 
but great care should be exercised to use no more force in applying 
the adhesive plaster or bandage than is necessary to accomplish this 
end, as it is easy to stop the circulation by pressure in this part. 
There should be some spring felt when the splints are pressed to- 
gether after their application. A bandage is to be applied over 
the splints and strips of plaster, beginning at the wrist and covering 
the forearm to the elbow, using the same care not to put the bandage 
on too firmly. The forearm is then to be held in the same position 
by a wide sling, as shown in Fig. 17. 

Four weeks are required to secure firm union after this fracture. 

When the fracture is compound the same treatment should be 
employed as described under Compound Fractures. 




Fig. 18'. — Fracture of the Wrist. 



FRACTURE OF THE WRIST 

(Colles* Fracture) 

This is a break of the lower end of the bone on the thumb side 
of the wrist, and much the larger bone in this part of the forearm. 

The accident happens 
when a person falls 
and strikes on the 
palm of the hand; it 
is more common in 
elderly people. A 
peculiar disfigure- 
ment, known as silver fork deformity, results. 

Symptoms. — A hump or swelling appears on the back of the 
wrist, and a deep crease is seen just above the hand in front (Fig. 
18). The whole hand is also displaced at the wrist toward the 
thumb side. One is not usually able to detect abnormal motion in 
the case of this fracture, or to hear any grating sound on manipu- 
lating the part, as the ends of the fragments are generally so 
jammed together that it is necessary to secure a surgeon as soon 
as possible to pull them apart under ether, in order to remedy the 
existing "silver-fork" deformity (see Fig. IS . 

Treatment. — Until medical aid can be obtained the same sort 



SPECIAL FRACTUKES 71 

o¥ splints should be applied, and in the same way as for the treat- 
ment of fractured forearm. If the deformity is not relieved a stiff 
and painful joint usually persists. It is sometimes impossible for 
the most skillful surgeon entirely to correct the existing deformity, 
and in elderly people some stiffness and pain in the wrist and 
fingers are often unavoidable results. 

FRACTURE OF BONE OF HAND OR FINGER 

Fracture of the hand is due to a blow on the knuckles. 

Symptoms. — This accident more commonly happens to the bones 
corresponding to the middle and ring finger, and occurs between the 
knuckle and the 
wrist, appearing as a 
swelling on the back 
of the hand. On 
looking at the closed 
fist from behind it 
will be seen that the 
knuckle correspond- 
ing to the broken -Fig. 19. — Break of the Bone in the Back of the Hand 

Corresponding to Right Middle Finger. 

bone in the back of 

the hand has ceased to be prominent, and has sunken down below 
the level of its fellows. The end of the fragment nearer the wrist 
can generally be felt projecting up in the back of the hand, while 
the end of the lower fragment is sometimes felt in the palm. 

Treatment. — If the finger corresponding to the broken bone in 
the back of the hand be pulled on forcibly, and the fragments be 
held between the thumb and forefinger of the other hand of the 
operator, pain and abnormal motion may be well detected, and the 
ends of the broken bone may be pressed into place. A thin 
wooden splint, as a piece of cigar box, about two inches wide at 
base and tapering to the width of the finger should be applied to 
the forearm and palm of the hand over the point of fracture. When 
there is not much displacement of the fragments of broken bone 
in the hand, or when either end of the broken bone projects toward 
the palm of the hand, a firm roll of bandage, large enough to be 
comfortably held in the hand, may be used as a splint. This is 




72 



FRACTURES OK BROKEX BOXES 



placed in the open palm of the injured hand and then each finger 
and knuckle is drawn firmly down over it, and the closed hand is 
held in place over the bandage by a broad strip of adhesive plaster, 
as in Fig. 19, or by a cotton bandage. Three weeks are required 
for a firm union; the hand should not be touched for a month. 

BROKEN FINGER 

Symptoms. — It is usually easy to recognize a broken bone in 
a finger, unless the break is near a joint, when it may be mistaken 

for a dislocation. Pain, abnormal mo- 
tion, and grating between the fragments 
are observed. 

Treatment. — If there is deformity, it 
may be corrected by pulling on the in- 
jured finger with one hand, while with 
the other the fragments are pressed into 
line. A narrow, padded wooden (half 
the thickness of a cigar box cover) or tin 
splint is applied, as in Fig. 20, reaching 
from the middle of the palm to the finger 
tip. Anv existing displacement of the 

Fig. 20. — Fractuee of the Fin- 

gee. Wooden Splint Applied broken bone can be relieved by using 

on Palm Side. . , -. . -, -, ~ i i i 

pressure with little pads oi cotton held 
in place by narrow strips of adhesive plaster where it is needed to 
keep the bone in line. The splint may be removed in two weeks and 
a strip of adhesive plaster wound about the finger to support it for a 
week or two more. 

In fracture of the thumb, the splint is often applied along 
the back instead of on the palm side. 




HIP FRACTURE 

A fracture of the hip is really a break of that portion of the 
thigh bone which enters into the socket of the pelvic bone and forms 
the hip joint. It occurs most commonly in aged people as a result 
of so slight an accident as tripping on a rug, falling on the floor 
from the standing position, making a misstep, or even attempting to 
avoid a fall. 



SPECIAL FRACTURES 73 

Symptoms. — When the accident has occurred the patient is un- 
able to rise or walk, and suffers pain in the hip joint. When he 
has been helped to bed it will be seen that the foot on the injured 
side is turned out, and the leg is perhaps shorter than its fellow. 
The patient cannot raise the heel of the injured leg from the bed. 
Shortening is an important sign. The shortening may be one-half 
an inch or so at first, but may increase to two inches within a few 
days. Shortening less than one-half inch is of no consequence as 
a sign of fracture. 

With a patient lying flat on his back and both legs straight to- 
gether in a line with his body, measurements are made with a tape 
or string to the bony prominence on the inside of each ankle. One 
end of the tape is held at the navel and the other swung from one 
ankle to the other, comparing the length of the two limbs. When 
the bony prominences on the inside of the two ankles can be brought 
together, shortening of one leg may be patent to the eye. If the 
broken leg cannot be brought into a straight line with the body, 
then the sound limb should be placed in the same position as the 
injured leg when the measurements are made. 

The fragments of broken bone are often jammed together (im- 
pacted) so that it is impossible to get any sound of grating between 
them, and it is very unwise to manipulate the leg or hip joint, 
except in the gentlest manner, in an attempt to get this grating. If 
the ends of the fragments become disengaged from each other, it 
often happens that union of the break never occurs. 

If, after even a slight injury, an old person is unable to use one 
leg, a fracture of the hip should be strongly suspected, even if no 
sign of a fracture is discoverable. The x-ray will then solve the 
diagnosis. 

Treatment. — The treatment simply consists in keeping the patient 
quiet on a hard mattress, with a small pillow under the knee of 
the injured side and the limb steadied on either side by pillows or 
cushions until a surgeon can be obtained. If the patient with frac- 
tured hip must be transported, then the leg should be supported 
by splints as recommended for fracture of the shaft of the thigh 
bone (see Fig. 21). 



74 FRACTURES OR BROKEN BONES 

THIGH BONE FRACTURE 

Symptoms. — In fracture of the shaft of the thigh bone (be- 
tween the hip and knee), there is often great swelling about the 
break. The limb is helpless and useless. There is intense pain 
and abnormal position in the injured part, besides deformity pro- 
duced by the swelling. The foot of the injured limb is turned out 
or in, owing to a rolling over of the portion of the limb below the 
break. With both lower limbs in line with the body, and the 
patient lying on the back, measurements are made with a tape- 
measure or string from the navel to the prominence on the inside 
of either ankle joint. Shortening of the injured leg will be found, 
varying from one to over two inches, according to the overlapping 
and displacement of the fragments. 

Treatment. — To set this fracture temporarily, a board about five 
inches wide, and long enough to reach from the armpit to the foot, 
should be padded well with towels, sheets, shawls, coats, blanket 
or whatever is at hand; the padding can best be kept in place by 
surgeon's adhesive plaster, bicycle tape, or strips of cloth. A bed 
slat or fence paling will do. Another splint should be provided as 
wide as the thigh and long enough to reach along the back of the 
leg from the middle of the calf to the buttock, and also padded in 
the same way. A third splint should be prepared in the same 
manner to go inside the leg, reaching from the crotch to the inside 
of the foot. Still a fourth splint made of thin (one-fourth inch) 
board as wide as the thigh, extending from the upper part of the 
thigh to just above the knee, should be padded for application to 
the front of the thigh. 

When these are ready and at hand, the leg should be pulled 
on steadily but carefully, straight away from the body to relax 
the muscle, an assistant holding the upper part of the thigh and 
pulling in the opposite direction. Then, when the leg has been 
straightened out and the thigh bone seems in fair line, the splints 
should be applied; the first to the outside of the thigh and body; 
the second under the calf, knee, and thigh ; the third to the inside 
of the whole limb; and the fourth to the front of the thi°h. 



SPECIAL FRACTURES 75 

Wide pads of folded sheet should be placed over the ribs under 
the outside splints to fill the space above the hips and under the 
armpit. Then all four splints should be drawn together and held 
in place by adhesive plaster straps or strips of strong muslin applied 
as follows : one above the ankle ; one below the knee ; one above the 
knee; one in the middle of the thigh; and one around the upper 
part of the thigh. A wide band of strong muslin or sheeting should 
then be bound around the whole body between the armpits and 
hips, inclosing the upper part of the outside splint. 

Following this, the patient can then be borne comfortably upon a 
stretcher made of boards and a mattress or some improvised cushion 
(see Fig. 21). 




Fig. 21. — Splints Used in Transportation in Case of Fracture of Shaft of Thigh. 

When the patient can immediately be put to bed after the injury, 
and does not have to be transported, it is only necessary to apply 
the outer, back and front splints, omitting the inner splint. In 
emergencies where only one splint is obtainable the outer is the im- 
portant one. It should be attached to the leg and body as de- 
scribed above and shown in Fig. 21. The foot should also be 
bandaged to the splint to prevent it from rolling out or in. The 
bandages binding the splint to the leg and body may be slipped 
under the patient without lifting either his body or limb. 

It is necessary for the proper and permanent setting of a frac- 
tured thigh that a surgeon give an anesthetic and apply the splints 
while the muscles are completely relaxed. It is also very essential 
that the muscles be kept from contracting thereafter by hanging a 
fifteen or twenty-pound weight to the injured leg, after the splints 
are applied. It is only possible to outline here the proper first-aid 
treatment. 



76 FRACTURES OR BROKEN" BONES 

KNEEPAN FRACTURE 

Fracture of the kneepan is caused either by direct violence or 
muscular strain, as in trying to recover one's balance after tripping 
or slipping. It more frequently occurs in young adults. 

Symptoms. — Immediate pain is felt in the knee and walking 
becomes impossible; in fact, often the patient cannot rise from 
the ground after the accident. He may, however, be able to stand_ 
after being assisted to his feet, but can only move backward by 
dragging the foot of the injured leg along the ground. Swelling 
at first is slight but increases enormously within a few hours, and 
it may be impossible then to recognize the existence of fracture 
until the swelling subsides. Immediately after the injury, however, 
it may be possible to feel the separate broken fragments of the knee- 
pan and to recognize that they are separated by a considerable space, 
if the break is horizontal across the bone. 

Treatment. — Nothing can be done to set the fracture until the 
swelling about the joint has been reduced; so that the first treat- 
ment consists in securing immediate rest for the knee joint, and 
immobility of the fragments. A splint made of board, about a 
quarter of an inch thick and about four inches wide for an adult, 
reaching from the upper part of the thigh above, to a little above 
the ankle below, is applied to the back of the limb and well padded 
with a folded sheet, extra layers being placed beneath the first to 
fill the space behind the knee. The splint is attached to the limb 
by straps of adhesive plaster two and one-half inches wide: one 
around the lower end of the splint, one around the upper part, and 
the third, just below the knee. To prevent and arrest the swelling 
and pain, pressure is then made on the knee by bandaging. 

One of the best methods (Scudder's) is to bandage two large, 
flat, dry sponges over the knee, one on each side, and pour cold 
water over them. They swell, exert firm and even pressure and 
prevent swelling of the joint. After twelve hours new sponges should 
be employed (the first set may be dried and pressed flat for use 
again) or a rubber bandage may be applied over the knee and then 
an icebag. But a splint is the first reauisite in anv case. 



SPECIAL FRACTURES 77 

The patient should of course be put to bed as soon as possible 
after the accident, and should lie on his back with the injured leg 
elevated on a pillow with a cradle to keep the clothes from pressing 
on the injured limb. 

FRACTURE OF LEG BONES BETWEEN KNEE AND ANKLE 

Symptoms. — In fracture of the leg between the knee and ankle 
we have pain, angular deformity or an apparent false joint in the 
leg, swelling and tenderness over the seat of fracture, together with 
inability to use the injured leg. Two bones form the framework 
of the leg; the inner, or shinbone, the sharp edge of which can be 
felt in front throughout most of its course, being much the larger 
and stronger bone. When both bones are broken the displacement 
of the fragments, abnormal motion and consequent deformity are 
commonly apparent, and a grating sound may be heard. 

An open wound often communicates with the break, making the 
fracture compound — a much more serious condition. To avoid mak- 
ing the fracture a compound one, during examination of the leg, 
owing to the sharp ends of the bony fragments, the utmost gentle- 
ness should be used. Under no circumstances should an attempt be 
made to move the fragments from side to side or backward and 
forward, in an effort to detect the grating sound often caused by 
the ends of broken bones. The greatest danger lies in the desire 
to do too much. 

When one bone is broken there may be only a point of tender- 
ness and swelling about the vicinity of the break and no displace- 
ment or grating sound. When in doubt as to the existence of a 
fracture the limb should always be treated as if a fracture were 
present. "Black-and-blue" discoloration of the skin, much more 
extensive than that following sprain, will become evident over the 
whole leg within twenty-four hours. 

Treatment. — When a surgeon cannot be obtained, the following 
temporary pillow dressing, recommended by Scudder in his book 
on fractures, is one of the best. With the patient on his back — 
the leg having been straightened and any deformity removed as 
far as possible by grasping the foot and pulling directly away from 



TS FBACTUBES OE BROKEN BOjSTES 

the body while an assistant steadies the thigh — a large, soft pillow, 
inclosed in a pillow case should be placed under the leg and pinned 
together along the front of the latter. The open end of the pillow 
case is folded and pinned over the sole of the foot. 




Fig. 22. — First Aid Treatment of Fracture of Both Bones. 



Then three strips of wood about four inches wide, three-six- 
teenths to one-quarter of an inch thick, and long enough to reach 
from the sole of the foot to about four inches above the knee, are 
placed outside of the pillow along the inner and outer aspects of 
the leg and beneath it. The splints are held in place, with the 
pillow as padding beneath, by four leather straps (or if these can-- 




Fig. 23. 



-Umbrella Used as Temporary Splint in Fracture of the Leg. 
Doty's "Prompt Aid to the Injured.") 



(After 



not be obtained, by strips of bandage, stout cloth, adhesive plaster, 
or even rope) ; and four pads made of folded towels should be put 
under the straps where they cross the front of the leg, at which 
place little but the pillow case overlaps. These straps are applied 
thus: one above the knee, one above the ankle, and the other two 
between these two points, holding all firmly together. This dress- 



SPECIAL FRACTURES 79 

ing may be left undisturbed for a week if necessary. The leg should 
be kept elevated after the splints are applied, and steadied by pil- 
lows placed on either side of it (see Fig. 22). 

From one to two months are required to secure union in a broken 
leg in adults, and from three to five months elapse before the limb 
is completely serviceable. In children the time requisite for a cure 
is usually much shorter. In Fig. 23 is shown a method of first- 
aid, temporary care of a fracture of the leg in order to remove a 
patient to a surgeon for proper treatment. It is a poor method 
compared to that described. 

ANKLE JOINT FRACTURE 

A fracture of the ankle joint is really a fracture of the lower 
extremities of the bones of the leg. 

Symptoms. — There are present pain and great swelling, par- 
ticularly on the inner side of the ankle at first, and the whole foot 
is pushed and bent outward. The bony prominence on the inner 
side of the ankle is unduly marked. The foot, besides being bent 
outward, is also displaced backward on the leg. This fracture 
might be taken for a dislocation or sprain of the ankle. Dislo- 
cation of the ankle without fracture is very rare, and when the 
foot is returned to its proper position, it will stay there, while in 
fracture the foot drops back to its former displaced state. In 
sprained ankle there are pain and swelling, but not the deformity 
caused by the displacement of the foot. 

Treatment. — This fracture may be treated temporarily by re- 
turning the foot to its usual position and putting on side splints 
and a back splint, as described for the treatment of fracture of 
the leg. 

FRACTURE OF THE BONES OF THE FOOT 

Fracture of the bones in front of the instep, corresponding to 
those of the palm of the hand, is caused by crushing violence. The 
bones (metatarsal — of which there are five) most likely to be broken 
are the inner and outer ones connecting with the big or little toe. 

Symptoms. — There is a painful and swollen area on the foot and 
abnormal movement and grating may be felt between the broken 



80 FRACTURES OR BROKEN BONES 

fragments. The deformity is slight, but the patient cannot bear 
his weight on the foot. 

Treatment. — The patient must keep his foot upon a chair, 
bed, or sofa. The broken bones should be pressed in place and 
kept there by a splint made of moistened heavy pasteboard or 
heavy felt, molded to one side of the leg and foot — reaching from 
the middle of the calf to the tips of the toes — on the injured side. 
This is kept in place by a bandage. The foot is held at right 
angles with the leg. If there is an open wound in connection with 
the fracture the case is much more serious and demands the imme- 
diate care of a surgeon {see Compound Fractures). 

Fracture of the toes is not common except from a crush of the 
foot. A large, thin, padded, tin splint, covering the whole sole of 
the foot and undersurface of the broken toe, is held in place by 
adhesive plaster strips and bandage. Union occurs in three or four 
weeks. 

COMPOUND OR OPEN FRACTURE OF THE LEG 

A fracture, connecting with an external wound, is said to be com- 
pound. The broken bone may or may not project through the ex- 
ternal wound. The wound may be produced either by the same vio- 
lence which caused the fracture, or by the end of a bony fragment 
piercing the muscles and skin from within. In either event the 
result is much more serious than that of an ordinary simple frac- 
ture, for germs can gain entrance through the wound in the skin 
and cause inflammation with partial destruction or death of the 
part. 

Treatment — Immediate treatment is here of the utmost value — 
the usefulness of the limb and the life of the patient depends upon 
it. This is applicable to open or compound fracture of any part 
of the body. 

The clothing should be carefully cut away from the limb. As 
a first-aid treatment the use of iodin is as valuable as the prolonged 
washing described below, and much simpler. After exposing the 
wound, remove bits of clothing or other dirt in it by means of 
forceps or hat pin (previously boiled five minutes), being sure not to 
touch the wound or its borders with the fingers. If there is much 



SPECIAL FRACTURES 81 

bleeding this must be controlled by tying a bandage tightly around 
the leg above the knee — to remain until the patient is placed in 
bed with the foot raised. Pour a little iodin (half alcohol and 
half tincture of iodin) into the wound so that it will come in contact 
with every part of it. Then swab the skin for an area two inches 
wide about the wound with the same mixture. This may be done 
with a piece of absorbent cotton wound on a stick. If a fragment 
of bone projects from the wound this should be thoroughly covered 
with iodin, and restored to place, as advised below. A strip of 
sterile gauze should also be thrust down into the wound to afford 
drainage, and this should be removed in three days. 

If the wound is small or if a surgeon can be obtained within 
a day or so this need not be done. Then a thick pad of dry, sterile 
gauze covered by absorbent cotton, the whole at least two inches 
thick, should be laid on the wound and bandaged to the leg. When 
no sterile gauze is to be had one may place several layers of cotton 
cloth (previously boiled five minutes) over the wound by means 
of a pair of forceps or two ordinary forks (previously boiled), the 
object being not to touch the dressing or the wound with the hands. 
A dry dressing is, however, preferable as water on top of iodin on 
the skin causes some irritation. Eo shaving or washing is thus 
required when iodin is used. When iodin is not at hand the fol- 
lowing procedure is to be employed. 

The area for a considerable distance about the wound, if cov- 
ered with hair, should be shaved. It should next be washed with 
warm water and soap by means of a clean piece of cotton cloth or 
absorbent cotton, protecting the wound meanwhile from any soiling 
by covering it, temporarily, with a pad of sterile gauze or boiled 
absorbent cotton. Then some absorbent cotton or cotton cloth should 
be boiled in water in a clean vessel for a few minutes, and, after 
the operator has thoroughly washed his hands, the boiled water 
(when sufficiently cool) should be applied to the wounded area and 
surrounding parts with the boiled cotton, removing in the most 
painstaking way all visible and invisible dirt. By allowing some 
of the water to flow over the wound from the height of a few feet 
this result is favored. Finally some of the boiled cotton, which 



FRACTURES OR BROKEN BOXES 

has not been previously touched, is spread over the wound wet, 
and covered with clean, dry, absorbent cotton, and bandaged. 

Splints are then applied, as for simple fracture, in the same 
locality. If a fragment of bone projects through the wound it 
may be replaced, after the cleansing just described, by grasping 
the lower part of the limb and pulling it in a straight line away 
from the body, while an assistant holds firmly the upper part of 
the limb and pulls in the opposite direction. During the whole 
process neither the hands of the operator nor the boiled cotton 
should come in contact with anything except the vessel containing 
the boiled water and the wound. 

The insertion of a strip of gauze for drainage is necessary, as 
described above, unless the case can be seen by a surgeon within 
twenty-four hours. The future treatment of the case is exactly 
similar to that of wounds generally. The first dressing need not 
be disturbed at all for a week or more, unless there is fever, or 
the dressing becomes soaked through with discharge, or a gauze strip 
has been inserted for drainage and which must be removed. If 
there is then no pus in the wound, it should be covered with dry, 
sterile gauze and not disturbed for a week more, unless fever appears. 



CHAPTER V 

DISLOCATIONS 

Dislocations of the jaw, shoulder, elbow, hip, thumb, and fingers. 

A dislocation is an injury to a joint wherein the ends of the 
bones forming a joint are forced out of place. A dislocation is 
commonly described as a condition in which a part (as the shoul- 
der) is "out of joint" or "out of place." 

Dislocation as Distinguished from Sprain and Fracture Near a 
Joint. — A dislocation must be distinguished from a sprain, and from 
a fracture near a joint. In a sprain, as has been stated, the bones 
entering into the formation of the joint are perhaps momentarily 
displaced, but return into their proper place when the violence is 
removed. But, owing to greater injury in dislocation, the head of 
the bone slips out of the socket which should hold it, breaks through 
the ligament (capsule) surrounding the joint, and remains perma- 
nently out of place; for this reason there is a peculiar deformity, 
produced by the head of the bone's lying in its new and unnatural 
situation, which is not seen in a sprain. 

Also the dislocated joint cannot be moved by the patient or 
by another person, except within narrow limits, while a sprained 
joint can be moved, with the production of pain, it is true, but with- 
out any mechanical obstacle. In the case of fracture near a joint 
there is usually increased movement in some new direction. When 
a. dislocated joint is put in proper place it stays in place, whereas 
when a fractured part is reduced there is nothing to keep it in 
place and, if left alone, it quickly resumes its former faulty position. 

Treatment. — There is no necessity for hurry in the case of most 
dislocations, as they may be reduced within twenty-four hours with 

83 



8-4 DISLOCATIONS 

as little danger as immediately after their occurrence. Of course 
the pain is relieved by their immediate treatment, this being im- 
perative when a surgeon is at command. On the other hand injury 
to vessels and nerves of a permanent character (paralysis) is not 
uncommon when much violence is used to reduce a dislocation, espe- 
cially by an unskilled person. The ideal method of treatment 
consists in giving ether to the patient, which immediately relaxes 
muscular spasm and allows of easy and painless reduction by the 
surgeon. This cannot be advised for the layman, however. When 
a surgeon can be obtained within a few days, and after a reasonable 
attempt has been used to reduce the dislocation, it is better to wait 
than to resort to persistent and violent efforts to get the bone into 
place. 

Only a few of the more common dislocations will be consid- 
ered here, as the others are of rare occurrence and require more 
skill than can be imparted in a book for the laity. The following 
instructions are not to be followed if skilled surgical attendance 
can be secured; they are intended solely for those not so fortunately 
situated. 

SPECIAL DISLOCATIONS 

DISLOCATION OF THE JAW 

This condition is caused by a blow on the chin, or occurs in 
gaping, or when the mouth is kept widely open during prolonged 
dental operations and during anesthesia. 

Symptoms. — The joint surface at the upper part of the lower 
jaw, just in front of the entrance to the ear, is thrown out of its 
socket on one side of the face, or on both sides. If the jaw is put 
out of place on both sides at once, the chin will be found projecting, 
so that the lower front teeth jut out beyond the upper front teeth, 
the mouth will be open and cannot be closed, and the patient will 
suffer considerable pain. When the jaw is dislocated on one side 
only, the chin is pushed over toward the uninjured side of the face, 
giving the face a twisted appearance ; the mouth is partly open and 
fixed in that position; a depression is seen on the injured side in 



SPECIAL DISLOCATIONS 85 

front of the ear, while a corresponding prominence exists on the op- 
posite side of the face; and the lower front teeth project beyond the 
upper front teeth. 

Treatment. — This is usually one of the easiest dislocations to 
reduce or put into place. A dislocation of one side of the jaw is 
treated in the same manner as that of both sides. 

The dislocation may sometimes be reduced, with the mouth opened 
to the widest extent, by placing a good-sized cork as far back as 
possible between the back teeth of the upper and lower jaws (on 
one or both sides according as the jaw is out of place on one or 
both sides), and getting the patient to bite down on the cork. This 
may pry the jaw back into place. 

The common method is for the operator to protect both thumbs 
by wrapping bandage about them or wearing leather gloves, and 
then, while an assistant steadies the head, the operator presses down- 
ward and backward on the back teeth of the patient on each side 
of the lower jaw with both thumbs in the patient's mouth. 

When the jaw slips into place it should be maintained there 
by a four-tailed bandage placed around the head and under the 
chin and retained there for a week (Fig. 13). During this time 
the patient should be fed on liquids through a tube, so that it will 
not be necessary for him to open his mouth to any extent. The 
surgeon will give the patient ether and will open the mouth wider, 
to stretch the ligaments on the sides of the jaws, and will then simply 
press the jaw gently backward and slightly downward with the 
thumbs on the outside of the jaw. 

DISLOCATION OF THE SHOULDER 

This is by far the most common of dislocations in adults, con- 
stituting over one-half of dislocations of all the other joints com- 
bined. It is caused by a fall or blow on the upper arm or shoulder, 
or by falling upon the elbow or outstretched hands. The upper 
part (or head) of the bone of the arm (humerus) slips downward 
out of the socket, or, in some cases, inward and forward. In either 
case the general appearance and treatment of the accident are the 
same. 



86 DISLOCATIONS 

Symptoms. — The patient sits with his body bent toward the 
injured side, holding the forearm with the hand of the sound side. 
The shoulder of the injured side loses its fullness and looks natter 
in front and on the side, the point of the shoulder being more 
prominent. If the arm is held with the elbow a few inches away 
from the side, the line of the arm will slope inwardly toward 
the shoulder, as compared with the sound arm. The elbow of the 
injured arm cannot be readily brought to the side of the chest. 
The injured arm cannot be moved much by the patient, although 
it can be lifted up and away from the side by another person, but 
cannot be moved so that the hand of the injured arm can be laid 
on the opposite shoulder. 

Treatment. — If a patient can be seen by a surgeon within a day 
or two, it is wiser to put the arm in a sling and bind the arm to 
the side with a large pad in the armpit, as in fracture of the collar 
bone, until the doctor can manage the case. Sometimes, however, 
gently pulling of the arm — as described below — will allow the bone 
to instantly fall into place with the greatest relief. 

As fractures about the upper part of the arm bone (humerus) 
are often mistaken for dislocations, it is always wiser to have an 
x-ray picture of the joint taken after a severe injury, especially 
if relief is not immediate when the supposed dislocation is reduced. 

One of the simplest methods (Stimson's) of reducing this dis- 
location consists of placing the patient on his injured side on a 
canvas cot, which should be raised high enough from the floor on 
chairs, and allowing the injured arm to hang directly downward 
toward the floor through a hole in the cot, the hand not touching 
the floor. Then a ten-pound weight should be attached to the 
wrist. The gradual pull produced by this means generally brings 
the shoulder back into place without pain, and within six minutes. 

Another simple method of reducing a dislocation of the shoul- 
der is the following: With the patient on his back, the arm 
should be brought to a right angle with the body and pulled with 
considerable steady force directly away from the shoulder, while 
an assistant should press the head, or upper part of the bone, up into 
the armpit. A third person, if available, should steady the body 



SPECIAL DISLOCATIONS S.7 

by means of a folded sheet passed about the chest, pulling on 
it away from the individual who is drawing out the injured arm. 
The bone will go back with a click which may be heard and felt, 
and the relief which the patient experiences is so sudden and great 
as to be almost painful. 

The ordinary and more violent method consists in putting the 
patient on his back on the floor, the operator also sitting on the 
floor with his stockinged foot against the patient's side under the 
armpit of the injured shoulder and grasping the injured arm at 
the elbow. He then pulls the arm directly outward (i. e., with the 
arm at right angles to the body) and away from the trunk. An 
assistant may at the same time aid by lifting the head of the arm 
bone upwards with his fingers in the patient's armpit and his thumbs 
over the injured shoulder. 

It is better to pull the arm away from the body as directed and, 
while pulling, bring the arm gradually to the side. 

If the arm does not go into place easily by one of these methods 
it is unwise to continue making further attempts. Also, if the 
shoulder has been dislocated several days, or if the patient is very 
muscular, it will generally be necessary for a surgeon to give ether 
in order to reduce the dislocation. It is entirely possible for a 
skillful surgeon to secure reduction of a dislocation of the shoulder 
several weeks after its occurrence. After the dislocation has been 
relieved the arm, above the elbow, should be bandaged to the side 
of the chest and the hand of the injured side be carried in a sling 
for ten days, as in the treatment of fractured collar bone. 

DISLOCATION OF THE ELBOW 

This is more frequent in children, and is usually produced by a 
fall on the outstretched hand. 

Symptoms. — The elbow is thrown out of joint, so that the fore- 
arm is displaced backward on the arm, in the more usual form of 
dislocation. The elbow joint is swollen and generally held slightly 
bent, but cannot be stretched out to any extent without great pain. 
The tip of the elbow projects at the back of the joint more than 
usual, leaving a gap between it and the back of the arm bone, while 



88 



DISLOCATIONS 



at the front of the arm the distance between the wrist and the bend 
of the elbow is less than that of the sound arm. 

For further proof that the elbow is out of joint we must com- 
pare the relations of three points in each elbow. These are the 
two bony prominences on either side of the joint (belonging to the 
bone of the arm above the elbow) and the bony prominence forming 
the tip of the elbow which belongs to the bone of the forearm. 

In dislocation backward of the forearm, the tip of the elbow 
is observed to be farther back, in relation to the two bony promi- 
nences at the side 
of the joint, than 
is the case in the 
sound elbow. 
This is best ascer- 
tained by touch- 
ing the three 
points on the pa- 
tient's elbow of 
each arm in turn. 

Fig. 24. — Dislocation Backward of Both Bones of the -rrnth fno thumb 
Forearm, Showing Position of the Ends of the Dis- 
located Bones, Deformity of Elbow, and Position and middle fin- 
of Forearm. 

ger, on each of 
the prominences on the side of the joint, while the forefinger is 
placed on the tip of the elbow. The lower end of the bone of the 
upper arm is often seen and felt easily just above the bend of the 
elbow in front, as it is thrown forward (see Fig. 24). 

Fracture of the lower part of the bone of the arm above the 
elbow joint may present much the same appearance as the dislo- 
cation we are describing, but then the whole elbow is displaced 
backward, and the relation of the three points described above is 
the same in the injured as in the uninjured arm. Moreover, in frac- 
ture, the deformity, when relieved, will immediately recur when 
the arm is released, as there is nothing to hold the bones in place ; 
but in dislocation, after the bones are replaced in their normal posi- 
tion, the deformity will not reappear. 

Treatment. — The treatment for dislocation consists in bending 




SPECIAL DISLOCATIONS 89 

the forearm backward, to a straight line, or even a little more, and 
then while an assistant firmly holds the arm above the elbow, the 
forearm should be grasped below the elbow and pulled with great 
force away from the assistant and,, while exerting this traction, the 
elbow should suddenly be bent forward to a right angle, when the 
bones should slip into place, often with a loud snap. 

The aftertreatment consists in binding the arm of the injured 
side to the chest and the use of a large sling, as recommended for 
treatment of broken collar bone. The sling should be removed after 
the second day and the elbow joint slightly moved by another person 
to prevent stiffness. This, with rubbing about the joint, should be 
done for five minutes each day and then the sling should be reapplied 
and continued for two or three weeks. 

A dislocation of the elbow is often complicated with a fracture, 
so that a surgeon's services are always demanded and the aid of an 
x-ray picture is advisable. 

DISLOCATION OF THE HIP 

This occurs more commonly in males from fifteen to forty-five 
years of age, and is due to external violence. 

Symptoms. — In the more ordinary form of hip dislocation (dis- 
placement backward of the head of the thigh bone from its socket) 
the patient stands on the sound leg with the body bent forward, 
the injured leg being greatly shortened, the toes turned inward so 
much that the foot of the injured limb crosses over the instep of the 
sound foot. When the patient lies down the knee of the injured 
limb rests on the thigh above the knee of the sound leg. The in- 
jured limb cannot be moved outward and but slightly inward, yet 
may be bent forward. Walking is impossible. Pain and deform- 
ity of the hip joint are evident. 

The only condition with which this would be likely to be con- 
fused is a fracture of bone in the region of the hip. Fracture of the 
hip is common in old people, but not in youth or middle adult life. 
In fracture there is usually not enough shortening to be perceived 
with the eye ; the toes are more often turned out, and the patient can 
often bear some weight on the limb, and even walk. 



90 DISLOCATIONS 

Treatment. — The most simple treatment is that recommended by 
Stimson. as follows: The patient should lie, face downward, upon 
a table with the uninjured leg held horizontally by one person, while 
another person (with the injured thigh hanging down vertically and 
leg at right angles) grasps the patient's ankle and gently rocks it 
from side to side — after placing a rive to ten-pound sand bag, or 
other object of similar weight, on the bend of the knee. Dr. Stim- 
son frequently uses no weight on the injured leg but relies on the 
weight of the thigh to pull the bone into place, when held in the 
described position with the muscles relaxed. He, however, often 
uses ether to secure complete relaxation. Stimson states that in only 
two instances has he failed to reduce this dislocation by this means. 
TVhen the dislocation has been overcome the patient should rest in bed 
for a week or two and should then go about gradually on crutches 
for a term of two weeks longer. 

DISLOCATION OF THE THUMB AND FINGERS 

This accident is usually due to a bending of the thumb or fingers 
backward. 

The Thumb 

In the case of the thumb, the separation and position of the dis- 
located bones (together with the deformity produced in the external 
appearance of the thumb) constitute a difficult dislocation to reduce. 
even under ether, and sometimes the surgeon is compelled to resort 
to a cutting operation. 

Treatment. — The reduction is attempted by bending and at the 
same time pulling the thumb forcibly backward while the head of 
the bone is being pressed forward into its proper place. 

A padded splint, reaching from the tip of the thumb to the wrist, 
should be applied to the palm side of the thumb and held in place 
by encircling strips of adhesive plaster. It should be retained for 
five days, when it may be removed, and slight movements and mas- 
sage of the joints may be begun. 



SPECIAL DISLOCATIONS 91 

Finger Joints 

Treatment. — Dislocation of the finger joints may be reduced by 
forcible pulling of the finger in a straight line away from the hand 
while twisting the bone slightly in one direction or another to aid 
the dislocated end to slip back into position. It is very much easier 
to accomplish a reduction at once than a few days later. The finger 
should be bandaged on a splint for five days, as for fracture, and 
then followed by massage, gentle movements, and soaking of the 
injured finger in hot water. 



CHAPTER VI 

SURGICAL DRESSINGS AND BANDAGES OF VARIOUS KINDS 
FOR DIFFERENT PARTS OF THE BODY 

Surgical dressings. Bandages of the limbs, including T -bandage, figure- 
of-eight bandage, spica of foot, triangular bandage of foot. Bandages 
of the head, breast, and shoulder, including triangular bandage of the 
head, triangular bandage of the breast, cravat bandage of the jaw, 
cravat bandage of the eye, cravat bandage of the shoulder. Transporta- 
tion of the injured. 

SURGICAL DRESSINGS 

Sterilized gauze is the chief surgical dressing of the present day. 
This material is simply cheesecloth, from which grease and dirt 
have been removed by boiling in some alkalin preparation — usually 
washing soda — and rinsing in pure water. The gauze is sterilized 
by subjecting it to moist or dry heat. Sterilized gauze may be bought 
in quantities of one yard upwards at shops dealing in surgeons' 
supplies and instruments, and at most drug stores. Gauze or cheese- 
cloth may be sterilized (to destroy germs) by baking in a slow oven 
in tin boxes, or wrapped in cotton cloth, until it begins to turn brown. 
It is well to have a small piece of the gauze in a separate package, 
which may be inspected from time to time in order to see how the 
baking is progressing, as the material to be employed for surgical 
purposes should not be opened until just before it is to be used, any 
remainder being immediately covered again. Cut the gauze into 
pieces as large as the hand, before it is sterilized, to avoid cutting 
and handling afterwards. Gauze may also be sterilized by steaming 
in an Arnold sterilizer, such as is used for milk, or by boiling ten 
minutes, if it is to be applied wet. Carbolized, borated, and corrosive 
sublimate gauze have little special value. 

92 



BANDAGES 93 

Absorbent cotton is also employed as a surgical dressing, and 
should also be sterilized if it is to be used on raw surfaces. It is 
not so useful for dressing wounds as gauze, since it mats down closely, 
does not absorb secretions and discharges so well, and sticks to the 
parts. When torn into balls as large as an egg and boiled for fifteen 
minutes in water, it is useful as sponges for cleaning wounds. Sheet 
wadding or cotton is serviceable in covering splints before they are 
applied to the skin. 

Wet antiseptic surgical dressings are valuable in treating wounds 
which are inflamed and are not healing well. They are made by 
soaking gauze in compound creosol solution, one teaspoonful to the 
pint of water, or (1 to 3,000) corrosive sublimate solution, and 
after application, covering the gauze with oil silk, rubber or paraffin 
paper. Heavy brown wrapping paper, well oiled or greased, will 
answer the purpose when better material is not at hand. 



BANDAGES 

Bandaging is an art that can only be acquired in any degree of 
perfection by practical instruction and experience. Some useful 
hints, however, may be given to the inexperienced. 

Cotton cloth or muslin, bleached or unbleached, is commonly 
employed for bandages; also gauze (not so effective a dressing but 
much easier of application), which is softer and more comfortable, 
and is best adapted to the use of the novice. A bandage cannot 
be put on properly unless it is first rolled. A bandage for the 
limbs should be about two and one-half inches wide and eight yards 
long ; for the fingers, three-quarters of an inch wide and three yards 
long. The bandage may be rolled on itself until it is as large as the 
finger and then rolled down the front of the thigh, with the palm of 
the right hand, while the loose end is held taut in the left hand. 

Boiled gauze bandages, sterilized and wrapped separately in 
paper, are sold at all drug stores. 



94 



SURGICAL DRESSINGS AND BANDAGES 





BANDAGES 



95 



Bandages of the Limbs 

Two forms of bandages are adapted to the limbs, the figure-of- 
eight bandage, and the spiral reversed bandage. In applying a 
bandage always begin at the lower extremity of the limb and approach 
the body. Make a few circular turns about the limb, from left to 
right, with the bandage coming from the under part of the roll. The 
object of making several complete turns of the bandage, over the same 
circumference of the limb, is to lock and keep the free end from slip- 
ping. Then as the limb enlarges, draw the bandage up spirally, re- 
versing it each time it encircles the limb, as shown in Figs. 25 and 
26. In reversing, hold the bandage with the left thumb or forefinger 
so that it will not slip, and then allowing the free end to fall slack, 
turn down as in Figs. 25 and 26. 



T-BANDAGE 

The T-bandage is used to bandage the crotch between the thighs, 
or around the forehead and over the top of the skull (see Fig. 
27). In the former case the ends 1-1 are put about the body as a 





Fig. 27.— T-Bandage. (After Weeks- 
Shaw "Textbook of Nursing.") 



Fig. 28. — Figure-of-Eight or 
Spica Bandage of the 
Thigh. 



belt, and the end 2 is brought from behind, in the narrow part of 
the back, down forward between the thighs, over the crotch, and 
up to the belt in the lower part of the belly. The figure-of-eight 
bandage is used on various parts, and is illustrated in the bandage 



96 SURGICAL DRESSINGS AND BANDAGES 

called spica of the groin (Fig. 28). Beginning with a few 
circular turns about the body in the direction of 1, the bandage is 
brought down in front of the body and groin, as in 2, and then about 
the back of the thigh up around the front of the thigh, as in 3, across 
the back and once around the body and down again as in 2. The 
figure-of-eight of the neck and shoulder is applied in the same manner. 
Beginning by making a few complete circular turns about the neck, 
and coming from behind the neck down in front of the shoulder, 
under the armpit and back in front of the neck. 

SPICA— FIGURE-OF-EIGHT BANDAGE 

In the spica, or figure-of-eight of the shoulder, Fig. 29, four 
complete circular turns of the bandage are made at 1 around the 




Fig. 29. — Figure-of-Eight or Spica Bandage of the Shoulder. 

arm, and the bandage is then pased over the shoulder and across the 
front of the chest at 2, under the opposite armpit, returning across 



BANDAGES 



or 



the back and down over the front of the shoulder at 3, round under 
the arm again at 4. 

SPICA OF THE ANKLE AND FOOT 

The spica of the foot (Fig. 30) is also another figure-of-eight 
bandage. Pass a few complete circular turns of the bandage about 
the ankle and then bring the bandage along 
the outside of the heel of the (left) foot 
as at 1 and diagonally across the top of the 
foot to the base of the big toe 2. Then 
continue under the sole to the base of the 
little toe 3 and diagonally across the top of 
the foot again to the inside of the ankle 4, 
and so on. Other bandages appropriate to 
various parts of the body are also illus- 
trated that by their help the proper method 
of their application may be understood 
(see Figs. 31, 32, 33 and 34). The trian- 
gular bandage (Fig. 35) made from a 
large handkerchief or piece of muslin a 
yard square, cut or folded diagonally from 
corner to corner, will be found invaluable 
in emergency cases. It is easily and quick- 
ly adjusted to almost any part of the body, 
and may be used 'for dressing wounds, or 
as a bandage for fractures, etc. 

Fig. 30. — Figure-of-Eight 
Bandage of the Ankle 
and Foot. 




TRIANGULAR AND CRAVAT BANDAGE OF THE THIGH 

The apex of the triangle is secured, as shown in Figure 36, by a 
cravat bandage about the waist. The middle of the base of the tri- 
angle then falls over the front of the thigh while the ends are passed 
around the thigh in opposite directions and are tied in front. This 
may be used to hold dressings in place on the groin. 



98 SURGICAL DRESSINGS AND BANDAGES 




Fig. 31. — Figtjre-of-Eight of the Hand. Make two or three circular turns about 
the wrist in the direction of the arrow at (1). Then bring the bandage diagonally 
across the back of the hand at (2), passing under the palm and making a complete 
circular turn about the hand, returning at (4). Then make a complete circular turn 
about the wrist and begin over again. 




Fig. 32. — Gauntlet Bandage, Showing the Completion of the Bandage of One 
Finger. Begin by making a few circular turns of the bandage about the wrist and 
then bring it over the back of the hand, circle the finger and return as indicated by 
arrow and make another complete turn about the wrist and start as before. 



BANDAGES 



99 




Fig. 33. — Figure-of-eight of the Elbow. Application is begun by making several 
complete circular turns of the bandage about the elbow with the center of the bandage 
over the bend in the elbow, in front, and over the point of the elbow, behind. Then 
each time, in making the turns, one passes a little farther away from the center of the 
joint — up the arm and down the forearm. 




Fig. 34. — Spiral Reverse Bandage of Leg. 



100 



SURGICAL DRESSINGS AND BAXDAGES 



TRIANGULAR BANDAGE OF THE FOOT 

Place the middle of the hase of the triangle behind the ankle and 
bring the apex forward under the sole and up over the toes and top 



' x 




ZX 



zx 



Fig. 35. — Triangular Bandage Folded 
Once and Twice. 




Fig. 36. — Triangular and Cravat 
Bandage of the Thigh. 



of the foot to the ankle. The two ends of the base are then passed 
in opposite directions so as to cross in front of the ankle, enclosing. 




Fig. 37.— Triangu- 
lar Bandage of 

the Foot. 




Fig. 38. — Triangular Bandage of the 
Head. 



the apex, and are brought under the sole of the foot and tied together 
on the top (see Fig. 37). The apex is pinned toward the main 
part of the bandage. This will hold dressings on the foot. 






BANDAGES 



101 



Bandages of the Head, Breast and Shoulder 

TRIANGULAR BANDAGE OF THE HEAD 

The square of cloth is folded diagonally from corner to corner, 
forming a triangle. This is laid on top of the head with the base 
to the forehead and the apex (3) at the 
back (Fig. 38). The ends 1 and 2 are 
carried in opposite directions completely 
around the head and tied in front. The 
apex is then pulled tight and turned for- 
ward and fastened to the main part of the 
bandage. This is used to hold dressings 
on the head. This triangle is made into a 
cravat bandage by folding the apex to the 
base and repeating the same operation a 
number of times, as in Figure 35. FlG - 39.-Triangular Band- 

*^ AGE OF THE JtlEAD. 




TRIANGULAR BANDAGE OF THE BREAST 

The middle of the base of the triangle is held under the breast 
while one end (1) is carried over one shoulder and the apex (A) over 
the other shoulder, while the end (2) is passed under the armpit, and 




Fig. 40. — Triangular Bandage of the 
Breast. 



Fig. 41. — Cravat Bandage of the Jaw. 



102 



SURGICAL DRESSINGS AND BANDAGES 



all three ends are tied together behind. This is used to support 
the breast when inflamed. 

CRAVAT BANDAGE OF THE JAW 

The middle part of the cravat is placed under the chin and the 





Fig. 42. — Cravat Bandage 
of the Eye. 



Fig. 43. — Cravat Bandage of the 

Shoulder. 



ends are carried over the top of the head in opposite directions and 
are brought down and tied under the chin (Fig. 41). 

CRAVAT BANDAGE OF THE EYE 

Place the middle of the cravat over the injured head and tie in 
front (Fig. 42). 

CRAVAT BANDAGE OF THE SHOULDER 

Place the middle of the cravat under the armpit and cross the 
ends, as shown in Figure 43, tying them under the opposite annpit. 



TRANSPORTATION OF THE INJURED 

A temporary stretcher may be improvised from two or three 
coats or vests, or one overcoat, by turning the sleeves inside out, 
passing two poles through the sleeves, and buttoning the coats together 
underneath. 

Potato or grain sacks, or pillow cases, may be used in the same 



TRANSPORTATION OF THE INJURED 



103 



way, the poles passing in at the open end and out through holes in the 
bottom corners. A more convenient stretcher is made by rolling 
each side of a blanket or rug on a pole until the portion remaining 




Fig. 44. — Blanket Stretcher. 



is about twenty-two inches wide. The blanket is then secured by 
cord about each pole through holes made for the purpose (see Fig. 
44). Two pieces should then be nailed or lashed across at each end 
of the stretcher to keep the poles apart. 



CHAPTER VII 
GKOWTHS AND SWELLINGS 

Tumors. New growths. Cancer. External swellings, as goiter, rupture, 
varicose veins, varicocele, piles. 



TUMORS 

A tumor — in its original meaning — signifies simply a swelling. 
As commonly used it means a new growth or enlargement of a part, 
not due to recent injury or inflammation. A tumor consists of tissue 
different from that natural to the part; its origin is unknown and 
it is capable of increasing indefinitely in size at expense of the body. 

Tumors occur at all ages in both sexes, and may attack any part 
of the body. Tumors are divided into two classes, benign and 
malignant. Benign tumors do not usually threaten the life of a 
patient unless by unusual size or situation, and they do not return 
when wholly removed. 

(1) Malignant Tumoks 

Symptoms of Malignant Tumors. — Malignant tumors tend to 
break down and become ulcerated. They are not clearly defined but 
invade the surrounding tissues to which they are often fixed so as 
not to move freely with the skin. Their borders are not well marked. 
They grow more rapidly than benign tumors, are often painful, and 
the skin may be attached to them. Malignant growths frequently 
give rise to secondary growths in the glands near by and in remote 
organs. They often return after removal either at the original site 
or in another part of the body. Cachexia is another symptom of 

104 



TUMORS 105 

cancer when it begins to ulcerate — not of early cancer. This means 
emaciation, pallor, loss of appetite and strength. 

Malignant tumors are divided into cancers and sarcomas although 
both may be roughly included under cancer. Cancer is much more 
frequent than sarcoma. Cancer occurs more often in middle life 
(45 to 55), the "cancer age" — occasionally between twenty and 
thirty years of age. 

(a) CANCER 

Causes of Cancer. — The cause of cancer is still unknown. Two 
theories predominate : one that cancer is caused by microscopic para- 
sites, the other that tissue cells assume unlimited capacity for growth 
by discarding, in some unknown manner, the usual control of the 
body over the growth of tissue. 

The microbes of cancer are always being reported but have never 
yet been discovered. We do not know enough about the causes of 
normal growth to interpret the causes of morbid growths. Certain 
frequently accepted beliefs concerning cancer have been discredited 
by recent knowledge. Thus there is no sufficient evidence to indicate 
that cancer is in any way contagious. 

While cancer may be unusually prevalent in certain localities and 
houses its contagiousness is not otherwise evident. Considering the 
frequency of cancer, which is apparently on the increase, it is not 
at all surprising to know of several cases in the same house, or in- 
stances in which both husband and wife are sufferers. One in every 
seven to twelve adults dies of cancer, according to statistics in various 
civilized countries. One woman in every eight women reaching the 
age of thirty-five years in the United States dies of cancer (Crile). 

Heredity is a doubtful cause in cancer, although in some fam- 
ilies (as, for instance, the Bonaparte family) its frequency is 
astonishing. 

One cause is certainly known to favor cancer and that is chronic 
irritation of a part. This has been the most valuable acquisition to 
our knowledge in recent years. As applied to special parts we know 
that cancer of the breast is caused by single blows and by chronic 
inflammation ; that cancer of the stomach follows usually upon chronic 
ulcer; that cancer of the womb is induced by the ulceration of old 



106 GROWTHS AND SWELLINGS 

tears originating in childbirth; that cancer of the gall-bladder is 
caused by the chronic irritation of gall-stones; that cancer of the 
skin is brought on by constant exposure to the sun and wind, or 
x-rays, or chemicals, as in those handling tar and paraffin. The 
great value of this knowledge lies in the fact that most of these causes 
may be avoided or remedied. 

Chronic white patches seen on the tongue or inside of the cheek 
of smokers and others frequently result in cancer. Hairy moles on 
the skin should be removed lest they eventuate in cancer. Chronic 
ulcer, persistent scaly patches on the face, or irritation about the 
angles of the eyes, nose, lips and tongue, and any chronic inflamma- 
tion of the skin, or other parts, should not be neglected, since they 
favor cancer. 

The increase in size of a mole, wart or birthmark in adults should 
demand instant removal, as such a condition often means the begin- 
ning of cancer. Injuries to bones, as fractures, apparently predis- 
pose to sarcoma. Injury is accepted as a cause of malignant tumor 
in countries awarding governmental pensions and indemnities. Some 
authorities, however, deny that injury is a cause of malignant tumor. 
Irritation of bad and sharp teeth may lead to cancer of the tongue 
or inside of the mouth. Cancer may originate in the severe scars 
of burns. It may be brought on in the kidney by the presence of 
stones; in the appendix through chronic inflammation. Cancer of 
the penis may be favored by the irritation of a tight foreskin. Cancer 
of the prostate gland is induced by chronic enlargement, so common 
in old men. 

Early Operation. — The moral to be deduced from the rehearsal 
of all these causes of cancer is plain. Such causative conditions 
should not be permitted to persist but should be removed promptly in 
the stage when surgery gives permanent cure. Physicians are 
greatly to blame for not always and everywhere preaching this doc- 
trine. The more common situations of cancer are in the lip and 
stomach of man and in the breast and womb of women. When 
cancer is allowed to grow there comes a time when the growth extends 
into the neighboring glands, which enlarge and are felt as lumps in 
the armpit, in cancer of the breast, and under the jaw in cancer of 



TUMORS 107 

the lip and mouth. It is most important that cancer should be 
removed before such extension occurs. 

Thus the chances of recovery are just reversed in cases with and 
without such evidences of extension. For example, in Johns Hop- 
kins University it is found that permanent cure results in eighty 
per cent, of cases of cancer of the breast when operation is done 
before there is enlargement of the glands in the armpit of the same 
side as the cancer ; whereas, in those cases operated after such involve- 
ment occurs, only twenty-five per cent, are permanently cured. 

The enlargement of glands in the neighborhood of cancer is a 
late sign and should never be permitted. Dr. Tyzzer has recently 
found that it takes exactly thirty-nine days after inoculation of 
cancer into mice before extension to neighboring parts ensues. 

Cancer of the Breast 

Symptoms. — Cancer of the breast begins as a lump in one breast, 
more often in the outer side and in the right breast. It may occur 
in either breast in any situation. It may be painless or painful. 
It is best felt by pressing the flat of the hand on the breast with the 
subject lying down, not by pinching a portion of the breast between 
the thumb and finger. Lumps occurring in the breast during nursing 
are usually inflammatory, but if these persist cancer may result. 
The appearance of any lump in the breast should demand the advice 
of a surgeon; also soreness of the nipples with any discharge from 
them. Frequently harmless (originally) growths become cancerous. 

Microscopical Examination. — The most skillful surgeon cannot 
always distinguish the difference between the harmless and malignant 
growths in the breast until microscopical examination is made at the 
time of operation. The rule follows that all lumps in the breast, not 
acutely inflammatory, should be removed by the knife — the extent of 
operation depending upon whether the growth proves cancerous 
or not. 

If this book had no other value than imparting this advice its 
publication would be fully justified because such information may 
make the difference between life and death. Every physician sees 
numerous cases, especially of cancer of the breast, where, through 



108 GROWTHS AXD SWELLINGS 

modesty, ignorance, or fear of operation, the patient waits until too 
late. This is precisely what one should never do in any suspicious 
tumor. Never wait until it is patent that the growth is cancer. 
Always have the tumor removed while its nature is doubtful. This 
is the only way in which permanently successful operations are 
secured. Xo reasonable objection can be made to such a course. 

All tumors of the breast should be removed as they may develop 
into cancer; their nature is determined absolutely at operation. If 
the tumor proves benign, so much the better. The knowledge that 
one has escaped a terrible danger is worth the operation, and one 
is rid of a growth which might have eventuated in cancer. There 
is no danger in operating on growths which do not require an extensive 
removal and even in the routine operation for cancer of the breast, 
where the whole breast and contents of the armpit are taken away, 
the death rate is but one in many hundreds of operations. 

Cancer of the Womb 

Cancer of the womb is more difficult of diagnosis, because less 
readily appreciated by the touch and eye. It occurs at the outlet 
of the womb at the site of old lacerations occurring in childbirth. 
It also attacks the body of the womb in both single and married 
women. 

Symptoms. — Those suggesting cancer of the outlet of the womb 
occur more often in women between thirty-seven and forty-seven 
years of age who have borne children. 

There are watery discharges which stain the clothing brown, fre- 
quency of urination and itching about the external parts, and slight 
bleeding between the periods — just enough to stain the clothes. Pain, 
flowing, and a bad smelling discharge come later. 

In cancer of the body of the womb symptoms appear after the 
"change of life" with the occurrence of a watery discharge and very 
little blood, at irregular periods, with also itching about the external 
parts. Later there are pain in the back and womb, and also flowing. 

Microscopical Examination. — Patients having any such symp- 
toms should at once submit to a physician's examination. In cases 
occurring after the change of life the womb should be curetted, or 



TUMORS 109 

scraped, in order to get tissue for microscopical examination. This 
is the only way. It is suicidal to delay. Cancer is always a local 
disease to start with and there is a time in the growth of every can- 
cer when its removal will be followed by permanent recovery. 

Cancer of the Stomach 

Cancer of the stomach has been described in detail elsewhere in 
this volume. Here, as in other cases of cancer, early operation gives 
the best results. The difficulty of making an early diagnosis is 
great. 

Cancer of the Lip 

Cancer of the lip begins as a small wart, sore or crack, in men 
over forty years of age generally. Its growth is very slow and it 
may seem a trivial matter. It may repeatedly scab but it does not 
heal. But any sore on the lip of a man over forty years is a serious 
matter and should demand the immediate attention of a surgeon, 
because its early removal will be attended with success. Not only the 
growth itself but the glands in the neck should always be removed to 
secure the best results. 

Popular Education. — Popular education is the sole means of 
curing cancer, for only when the public is informed as to the early 
signs of cancer, or the conditions which lead to cancer, will the 
surgeon get cases at a time when cure is possible. The general 
feeling that cancer is incurable arises from the fact that most cases 
of cancer in the past have not come to surgeons early enough. Cancer 
in its earliest or precancerous stage is readily and permanently cured 
by skillful surgeons. 

General Treatment. — Early removal by the knife is the only form 
of treatment to be considered in most cases. The x-ray is not com- 
monly advisable, except in some superficial malignant growths on 
the skin. Radium is much written about and may at some time be 
valuable in the cure of cancer. It is not an agent which can gener- 
ally be recommended for the cure of cancer at present. 

Some forms of electricity and heat (slow cooking) have appar- 
ently been very successful in the treatment of cancer in some parts 



110 GROWTHS AND SWELLINGS 

of the body, as in the bladder. It is too early to say that they will 
replace the knife, even in this locality. Treatment by all chemical 
pastes is simply courting disaster except in cases inoperable by the 
knife, when other means will often secure relief from suffering and 
prolong life — but not in the hands of advertising quacks. 

(b) SARCOMA 

The other form of malignant tumor, or sarcoma, is not nearly so 
common as cancer. It is often seen in the young and well nourished ; 
it grows very rapidly ; the skin is usually not adherent to the tumor ; 
there is generally no pain. The favorite seats are the bones, glands 
of the neck, muscles, the brain and many other localities. 

Summary. — Delay and neglect are suicidal in malignant disease. 
Cure is successful just in proportion as operation is done early. If 
dread of operation were less common the cure of cancer would be 
more common. The return of the disease after operation is due to 
the fact that the operation was done too late. The family physi- 
cian is often to blame in not advising early operation. Cancer 
should be removed at so early a stage that the diagnosis is not positive 
without microscopical examination. If the rule to remove all tumors 
were followed many cancers would never occur. The special reme- 
dies advertised to cure cancer are humbugs. 

(2) Be^igx Tumors 

There are many forms of the less harmful or benign tumors. 
These do not return if completely removed and do not endanger life 
unless they grow to a large size. Among these are the soft, flattened, 
fatty tumors of the shoulders, back, buttocks and other parts. The 
wen is common on the head and scalp, from the size of a pea to an 
egg, often appearing in groups. 

It would be a waste of time to try to describe the other forms of 
benign tumors because it would be impossible to tell the layman how 
to distinguish them from malignant growths. 



GOITER 111 



GOITER 



A goiter is an enlargement of the thyroid gland which is situated 
in front of the upper part of the windpipe in the neck and in the 
region usually covered by the collar. When a person with goiter goes 
through the act of swallowing, the goiter rises with the "Adam's 
apple" or with the larynx or windpipe. This will distinguish goiter 
from simply a large neck. Goiter is common in many parts of 
the world, as in Switzerland, England, and in this country in- the 
region of the Great Lakes, in the Northwestern states and California. 

Cause. — The cause of goiter is unknown. Drinking water is 
thought to be the chief medium for communicating the disease, and 
experimenters have found that boiling and filtering water prevents 
the occurrence of the disease in persons drinking it, while the residue 
in the (Berkefeld) filter will produce the disease. Also as the 
disease occurs sometimes in epidemics, it is probable that it is caused 
by a special germ. 

Symptoms. — The swelling in the neck may be quite general or it 
may be in the form of a distinct lump. The gland may often enlarge 
at puberty, but frequently the swelling disappears later. It usually 
becomes slightly enlarged during the time of menstruation in young 
women. 

A persistent, distinct enlargement is called goiter. Goiter may 
remain about the same size indefinitely and produce no symptoms ; if 
it continues to grow there may be pressure on the windpipe, with 
difficulty of breathing, hoarseness, cough, or difficulty in swallowing. 

Sometimes it will disappear permanently, but this occurs chiefly 
in young persons. It has been found that after a simple goiter 
persists for fourteen to sixteen years without causing any apparent 
trouble, it may then give rise to symptoms not unlike those described 
below under exophthalmic goiter. Changes in the secretion of the 
gland cause poisoning of the whole system with resulting degeneration 
of the heart, kidneys and liver. 

Thus we see the danger of allowing a simple goiter to remain 
indefinitely even if it occasions no noticeable discomfort or effects. 



112 GROWTHS AND SWELLINGS 

EXOPHTHALMIC GOITER 

This is a disease in which there is enlargement of the thyroid 
gland, protruding eyeballs, rapid pulse (100 to 140), and fine trem- 
bling of the hands and tongue. The vessels in the neck throb and 
the face is often hot and flushed and covered with perspiration. 
Digestive symptoms are common, as vomiting, diarrhea, and jaundice, 
and the patient becomes extremely nervous and excitable in some 
cases. There may be weakness in the legs as seen in making a high 
step. The patient frequently loses weight. In this form of goiter 
there is an excess of the normal secretion poured into the circulation 
which poisons the patient. 

MYXEDEMA 

When there is an insufficient secretion of the gland there is just 
the opposite condition (to exophthalmic goiter) with slow pulse, dull- 
ness, apathy and dry skin; the face becomes coarse and swollen, the 
cheeks pendulous, and the tongue enlarged. The hands and feet also 
swell ; thought and speech are slow and the gait is clumsy. This re- 
markable state is called myxedema. It occurs owing to wasting of 
the thyroid gland, or in some cases to goiter and inflammation of the 
gland, and will arise if the whole gland is removed. In the cretin, or 
child of goitrous parents, development is disturbed through lack of 
the thyroid secretion. Here we see a hideously distorted, imbecile 
dwarf, with large head, swollen protruding tongue and lips, large 
belly, and stumpy tottering limbs. 

Treatment of Goiter 
A simple goiter of moderate size and not producing any trouble. 
in persons under adult age, should be treated medically and it will 
often disappear. Some form of iodin is most often used. The dose 
of iodid of iron for children of twelve years would be eight drops 
and for adults fifteen drops. The powdered, dried, thyroid gland 
of sheep is often very successful but is too powerful a drug for the 
layman to use. The giving of two to five grains of sodium iodid in 
one-half glass of water once daily to young people will often cure 
simple goiter. 



RUPTURE 113 

When the gland is enlarging rapidly or steadily it should be 
surgically removed. A persistent goiter in adults may become can- 
cerous, or symptoms of poisoning (thyrotoxic symptoms) or of ex- 
ophthalmic goiter may develop. Moreover, it is a blemish. In these 
cases surgery is also advised. 

Since the mortality of goiter operations is slight in the hands of 
skillful surgeons, it is wise for adults to have the growth removed 
by an able surgeon. 

Exophthalmic goiter, of course, demands the sendees of a physi- 
cian. Complete rest in bed with an icebag on the heart will improve 
the condition. The same treatment which is useful for simple goiter 
will do harm in exophthalmic goiter, such as the use of the thyroid 
gland and iodin preparations. All sorts of treatment is recommended 
but no treatment equals the results of surgery by which seventy-five 
per cent, are absolutely cured or greatly improved. Of the remaining 
twenty-five per cent, twenty per cent, are greatly benefited, except for 
occasional relapses of rapid pulse and tremors. Preliminary x-ray 
treatment may make the operation more safe. Like most surgical 
conditions the result depends upon the progress of the disease when 
operation is done. Persons who defer surgery until they have tried 
all kinds of medical treatment — poor, bad and worse — are apt to 
suffer from changes in the heart and other organs which are irrep- 
arable. The results of surgery are marvelous in exophthalmic 
goiter. Feeding of the dried thyroid glands produces wonderful 
results in the cretin and in myxedema. 

Osier affirms that goiter may be prevented and cured in goitrous 
districts by drinking only boiled water. 



RUPTURE 

Hernia, or rupture, consists of a protrusion of a portion of the 
contents of the abdomen through the abdominal wall under the super- 
ficial tissues and skin. Commonly the protrusion is a part of the 
bowel or its fatty covering (omentum). The usual seats of rupture 
are at the navel and groin. Rupture at the navel is called umbilical 



114 



GROWTHS AND SWELLINGS 



hernia ; that at the groin either inguinal or femoral, according to 
slight differences in site. Umbilical hernia is common in babies 
and occurs as a whole in only five per cent, of all ruptures, whereas 
rupture in the groin constitutes ninety-four per cent. (Fig. 45). One 
per cent, of females and six and seven-tenths per cent, of males are 
ruptured (Kingdon). 

Rupture may also arise from the giving away of scars after 




Fig. 45. 



-Sites of Rupture. 1 and 2 Epigastric Hernia; 3 Umbilical Hernia; 4 In- 
guinal Hernia; 5 Femoral Hernia. 



abdominal operations, and will occur at almost any point at which 
there is a scar. It is chiefly in wounds which have been kept open 
for drainage that rupture arises. Rupture rarely follows in wounds 
which are closed at operation and heal without the formation of pus. 
Causes.- — -Rupture is sometimes present at birth. The ordinary 
cause of rupture is natural weakness of the structures at the points 
at which they ordinarily occur. Twenty-five per cent, of persons 
with rupture record a history of the same trouble in their parents. 
Rupture is six times more frequent in men than in women, and is 



RUPTURE 115 

favored by severe muscular work, obesity, chronic coughing, constipa- 
tion, diarrhea, straining to pass water, sudden strain in lifting, and 
blows on the abdomen. 

Symptoms. — Rupture first appears as a fullness or soft swelling, 
more noticeable on standing, lifting, coughing, or straining. It may 
disappear entirely on lying down or on pressure with the fingers. In 
the beginning there may be discomfort after standing or walking 
for any length of time, and later there is often a dragging pain or 
uneasiness complained of, or a sensation of weakness or griping at 
the seat of rupture. 

In case the rupture cannot be returned it is called irreducible, 
and is a more serious form. 

The great danger of ruptures is in the likelihood of their being 
strangulated — that is, so nipped between the muscles of the abdominal 
wall that the blood supply of the bowel is cut off and the bowel 
completely obstructed. If this condition is not speedily relieved 
death will ensue in from two to eight days. Strangulated hernia is 
one of the four surgical emergencies which, unrelieved, causes death. 
The other three are suffocation, severe bleeding, and urinary 
obstruction. 

Strangulation may be brought on in persons having rupture by 
heavy lifting, straining, coughing, or by a blow or fall, in forcing out 
more bowel or omentum than can be readily returned. The symp- 
toms of strangulated hernia are sudden and complete constipation, 
persistent vomiting, severe pain about the navel, or at the seat of 
rupture. 

The pain is often not attributed to the rupture, and doctors may 
fail to discover the true cause of the trouble by not always examining 
for rupture and by not asking the patient if there is one. The 
vomiting consists first, of the contents of the stomach, and then of 
yellowish stained fluid, and finally of dark material having the odor 
of excrement. The contents of the bowel come up "the wrong way" 
owing to the obstruction. Great weakness, distention of the belly, 
retching, hiccough, thirst, profound exhaustion, and death follow, if 
the condition is not at once remedied. 

In some cases where the obstruction is not complete, the symptoms 



116 GROWTHS AND SWELLINGS 

are comparatively mild — as occasional vomiting, slight pain, and 
partial constipation. 

Treatment. — If the patient cannot promptly return the protru- 
sion a surgeon should he secured at any cost, the patient, mean- 
while, lying in bed with an icebag or cold cloths over the rupture. 
The surgeon will reduce the rupture under ether or by operation. 
Strangulation of any rupture may occur but is less likely to happen 
in those who wear a well-fitting truss. 

Still it is always a dangerous possibility, and this fact together 
with the liability of the rupture to increase in size, make a surgical 
operation for complete cure advisable in proper subjects. 

Two means of treatment are possible — the wearing of a truss, 
and a surgical operation. By wearing a truss fifty-eight per cent, 
of ruptures recover completely in children under one year. In 
children from one to five years, with rupture, ten per cent, are cured 
by the truss. 

Statistics show that in rupture which has been acquired after 
birth but five per cent, recover with a truss after the age of fifteen, 
and but one per cent, after thirty. The truss must be worn two 
years after cure of rupture in children, and in adults the rest of 
their lives. 

A truss consists of a steel spring which encircles the body and 
holds in place a pad which fits over the seat of hernia. 

The truss is most satisfactory in ruptures which can be readily 
reduced. In very large or very small hernias, the action of a truss 
is not so effective. The truss should never be applied in hernias 
irreducible or but partially reducible. The pressure of the truss on 
the irreducible tissues may cause inflammation and perhaps gangrene 
and strangulation. Every person with a reducible hernia should 
wear a proper truss until the rupture is cured by some means. Such 
a truss should keep in the hernia without pain or discomfort. It 
should be taken off at night and replaced in the morning while the 
patient is lying down. In cases where the protrusion occurs during 
the night a truss must be worn day and night, but often a lighter 
form will serve for use in bed. To test the efficiency of a truss let 
the patient stoop forward with his knees apart, and hands on his 



VARICOSE VEINS 117 

knees and cough. If the truss keeps the hernia in it is suitable, if 
not, it is probably unsuitable. 

Operations for the complete cure of hernia are successful in 
ninety-five cases out of one hundred in ruptures in the groin, in suit- 
able subjects. The death rate is but one in five hundred to one 
thousand operations when done by surgeons skilled in this special 
work. Patients with very large hernias, those who are very fat and 
those in advanced years are unfavorable subjects for operation. In 
young men operation — if it can be done by a skilful surgeon in a 
hospital with all facilities — is usually to be recommended in every 
case of rupture. Irreducible ruptures should be operated on in 
most cases. Umbilical and ventral hernias, due to operations, may 
be held in place by a wide, strong belt about the body which holds 
a flat or circular plate over the rupture. 

These persons with umbilical hernia are usually the worst sort 
of patients for hernia operations, being very stout, of middle age or 
older, and without any muscular development. Hernias following 
operations may be cured by surgery if the tissues are sufficiently 
strong. 

Umbilical hernia in babies is very common after the cord has 
dropped off. There is a protrusion at the navel which increases in 
size on coughing, straining, or crying. If the rupture is pushed in 
and the skin is brought together from either side in two folds over 
the navel, so as to bury the navel out of sight, and held in this posi- 
tion by a strip of surgeon's adhesive plaster, reaching across the 
front of the abdomen and about two and one-half inches wide, com- 
plete recovery will usually take place within a few months. It is 
well to cover the plaster by a snug flannel band about the body. The 
plaster may be replaced as need be, and should in all cases be applied 
by a physician if one can be secured. 



VARICOSE VEINS 

Varicose veins are unnaturally, irregularly, and permanently 
dilated veins which are more commonly present on the inside of 



118 GEOWTHS AND SWELLINGS 

the legs but are also found on the outer side, and in the scrotum 
and lower bowel. (See Varicocele and Piles.) 

Symptoms. — They stand out on the skin as bluish, knotty, and 
winding cords which flatten out when pressure is made upon them 
and shrink in size when the patient lies down. Sometimes bluish, 
soft, rounded lumps, or a fine, branching network of veins may 
be seen. The skin over varicose veins is often discolored owing to 
escape of blood from the vein. Varicose veins occur in twenty 
per cent, of adults, and in eighty per cent, of cases they appear 
before the age of twenty-five. 

Frequently varicose veins are present for years without causing 
trouble, and without increasing in size. The writer has had quite 
marked varicose veins in one leg for thirty-five years without having 
felt the slightest inconvenience. In other cases they cause a feeling 
of weight and dullness in the legs, especially on standing. When 
they are extensive the legs may become swollen and hard, and 
eczema with itching is frequent. This leads to scratching and sores, 
or varicose ulcers, which are chronic and difficult to heal. 

Occasionally an old varicose vein may break open and give rise 
to profuse bleeding. Rarely the blood may clot in a varicose vein; 
this endangers the patient's life because of the possibility of the 
clot escaping into the circulation and plugging some vital vessel, 
as in the lung. If the swelling of a leg from varicose veins is 
increasing and marked the patient should remain in bed until a doctor 
decides if there be clotting of the blood in a vein. 

Causes. — Varicose veins are more common in women. It has 
been commonly taught that obstruction to the flow of blood in 
veins is the cause of their varicosity. Thus in pregnant women 
varicose veins of the leg are very common from supposed pressure 
of the womb. Piles are said to be due to pressure on the veins 
and obstruction to the flow of blood upwards in the lower bowel 
brought on by constipation, a pregnant womb, enlarged prostate 
gland, etc. But it has been shown that the veins enlarge in preg- 
nant women before the womb is big enough to press on them, and 
it is now generally recognized that there is some chemical change 
in the blood, or tendency in the veins to grow larger. Pressure 



VARICOCELE 119 

upon the veins, as by a garter about the leg or other of the causes 
mentioned, favor varicose enlargements, as well as poor circulation 
in heart, liver, and lung diseases. 

Treatment. — Varicose veins are exceedingly common and, if they 
are not very extensive and produce no discomfort, they may be ig- 
nored. Exercise in the open air is as desirable as lying down every 
afternoon, if possible. Massage of the affected leg with alcohol is 
desirable, if there is no eczema. If there is pain, discomfort, or 
swelling in the limb it is advisable to apply a flannel bandage (four 
inches wide and cut on the bias) from the toes to a point above the 
varicose veins. A rubber perforated bandage about three inches 
wide may be used in place of the flannel, if applied over a long 
stocking; or an elastic stocking sold by instrument dealers may be 
used. Whichever form of support is used it should be put on before 
rising in the morning and removed after the patient retires at night. 

Surgical operation will cure some varicose veins. It is not 
generally recommended, unless tumor-like dilatations form on the 
legs or a clot forms in the vein, or a thin-walled vein crosses the 
shin bone where it is liable to injury and the formation of blood clot. 

When the veins in the leg and large vein in the thigh (saphena 
vein) are both varicose, operation should be performed. Bleeding 
from a broken varicose vein is stopped by the pressure of a sterilized 
gauze bandage over the wound while the patient lies on his back 
with his foot raised by a pillow on a box. 



VARICOCELE 

This consists of an enlargement of the veins in the scrotum above 
the testicle of the male, on the left side in most cases. The large 
veins feel much like a bunch of earthworms with the testicle at 
the bottom. The testicle on the left side is apt to be somewhat 
smaller and softer than the one on the right. The skin of the 
scrotum commonly hangs down further on the side with the vari- 
cocele. If the enlargement of the veins causes no discomfort, it 
may be entirely neglected, as the swelling is not of the slightest 
consequence. When the swelling causes trouble there may be a dis- 



120 GROWTHS AND SWELLINGS 

comfort or dragging pain in the groin and testicle, and perhaps about 
the rectum and bladder. In some cases pain in the small of the 
back may be the only symptom. There are young men who become 
much depressed and melancholic on account of varicocele. Ad- 
vantage is taken of this fact by quacks, who find it to their profit 
to advertise all sorts of horrible and preposterous effects which result 
from varicocele. While, as has been noted, the testicle on the af- 
fected side may become soft and shrunken, this does not prevent 
the subject from having normal sexual powers nor does it take away 
his ability to propagate. Varicocele is a very slight and usually 
harmless disability. It occurred in one out of every five males in 
ten thousand recruits (Senn). 

Causes. — The spermatic vein on the left side empties into a large 
vein (renal) at right angles, while the right enters into the same 
vein on the other side at an acute angle and so the blood flows 
more freely from the right testicle. Some believe ungratified sexual 
excitement to be a cause. When a man reaches middle age a vari- 
cocele usually ceases to cause trouble. 

Treatment. — The patient needs to be assured emphatically that 
there is no danger of impotence in varicocele. He should take cold 
shower baths daily, or else bathe the scrotum in cold water for five 
minutes night and morning. Constipation, if present, should be 
cured. The application of a snugly fitting jockey strap, or sus- 
pensory bandage will give the most relief. The former is the most 
efficient and may be bought at athletic supply stores. When pain 
is considerable, the testicle much shrunken, and the patient desires 
a permanent cure, this may be secured by a surgical operation which 
does not endanger life and is a simple affair. The enlargement 
of the veins cannot be removed by the use of cold water and the 
support of a bandage, but usually they will give relief from the 
discomfort of varicocele. 

PILES 

{Hemorrhoids) 

Piles consist of enlarged veins at the outlet of the bowel. Not 1 
only is there a dilatation of the veins, but there is a growth of new 



PILES 121 

tissue about them so that they form little tumors. Piles are internal 
and external. 

External Piles 

Symptoms. — These are bluish swellings or little lumps which 
project from the bowel. They become inflamed at times, when they 
are itchy and exquisitely painful and tender so as to make walk- 
ing, sitting and bowel movements difficult. In the course of time 
these become mere tabs or fringes of flesh and cause no trouble, 
unless they become irritated, on account of uncleanliness or from 
some other cause. 

Treatment. — When there are external piles the parts should al- 
ways be washed with cold water after each movement of the bowels, 
to avoid irritation. The bowels should be kept regular in any form 
of piles and the patient should take one-half teaspoonful of aro- 
matic fluidextract of cascara sagrada at night or, in inflamed piles, a 
teaspoonful, more or less, of artificial Carlsbad, Epsom, or Glauber's 
salts in a whole glass of water on arising. 

Equal parts of sulphur and cream of tartar is an old-fashioned 
domestic remedy of which a teaspoonful may be taken each morning, 
if salts do not agree. If the external piles become inflamed, and 
the soreness is great, the patient should rest in bed and avoid the 
use of meat and tobacco. Ice water should be injected into the 
bowel three times daily and an icebag or hot poultice should be 
kept continually on the inflamed parts. The hot flaxseed poultice 
will probably give most relief. Certain drugs also are of much 
benefit. None is better than the old witch hazel extract applied 
frequently in a pure state. 

An ointment of nutgall and opium, kept by druggists, or gauze 
saturated with a mixture of boroglycerid one part, and water three 
parts, should be placed on the inflamed piles and kept warm with a 
hot-water bag. 

• While this treatment will usually give relief in time, surgery 
is the quickest method of cure by cutting into inflamed piles con- 
taining blood clots and removing the clots, or, in cases with inflam- 
mation of the folds of flesh about the anus, these may be cut away. 



122 GROWTHS AND SWELLINGS 



Internal Piles 



Symptoms. — These are enlarged veins which form little tumors 
just within the outlet of the bowel (anus) and are often protruded 
during movement of the bowels. They are soft, purplish, irregular 
lumps. When rubbed by the excrement in movement of the bowels 
they bleed; bleeding at the closet is the chief sign of internal piles. 

It is usually the only sign in uncomplicated cases. Later blood 
may be lost at other times, and the loss of blood may be so great 
as to cause pronounced paleness and weakness. There may also 
be some pain with the movement of the bowels but, when there is 
much pain during and after the movement, it is probable that there 
is also a fissure, crack or ulcer in the mucous membrane which needs 
surgical attention. Fissure of the bowel frequently exists without 
piles, is an exceedingly painful trouble, and may break down the 
nervous system owing to the violent burning pain which begins 
during the act of moving the bowels and may continue for some 
hours thereafter. 

Then with internal piles there is often bleeding, sometimes itch- 
ing and some pain during the movement. There may be some dis- 
charge of mucus from the bowel. Loss of sexual power and desire 
may rarely be due to piles. It not infrequently happens that the 
piles come out during the bowel movement, when they should be thor- 
oughly washed with cold water, greased with vaselin and put back. 
Sometimes this is impossible, but on lying down, with cold cloths 
or ice against the piles, the mass may shrink so as, to admit of its 
return. When a large mass is thus protruded and cannot be re- 
turned, and becomes nipped by the anus muscle, it undergoes inflam- 
mation and is very painful, but a cure may result from its destruction. 
Such a mode of cure is not a safe or desirable one, however. 

Examination. — Before speaking of treatment the writer would 
like to emphatically advise any person with piles to submit to a 
thorough examination of the inside of the lower bowel by a physician 
in order that the possibility of a tumor in the bowel may be excluded. 
Since piles is a common and comparatively harmless disorder it 
is apt to be treated without due care, and several cases in which 



PILES 123 

cancer was overlooked until too late have come to the author's notice. 
The occurrence of bleeding or pain in this region should always 
demand a proper examination by sight and touch to exclude the 
presence of new growths within the bowel. 

Treatment. — Medical treatment may temporarily stop the symp- 
toms, as pain and bleeding, but it cannot remove the dilated veins. 
When symptoms occur only occasionally such treatment may suffice. 
The patient must take regular exercise, give up overeating and drink- 
ing, and keep the bowels regular — as advised for external piles. 
The Carlsbad salts in the morning. is particularly indicated. After 
every movement of the bowels the external parts should be washed 
with cold water and then a pint of cold water should be injected 
into the bowel. When the water comes away the outer parts should 
be dried with a soft cloth. 

If the piles come out they should be returned after injecting 
the cold water and a suppository containing ten grains of extract 
of hamamelis, five grains of tannic acid and one-third grain of 
extract of belladonna, should be inserted in the bowel, and another 
should be inserted at bedtime. Two teaspoonfuls of the extract of 
witch hazel added to the cold water injections increase their value. 
If there is much itching an ointment containing thirty grains of 
orthoform in a half ounce of lard may be useful when introduced by 
the finger. The compound gall-ointment or glycerite of tannin may 
be found successful in some cases. They also are applied by inserting 
the finger into the bowel. 

The only positive cure for piles is surgical operation; this com- 
pletely removes them. Self-treatment of piles is not recommended, 
as a physician can do much better and an examination is always ad- 
visable and should be made with an instrument through which the 
physician can see into the interior of the bowel. By this means, and 
by introduction of the finger, the doctor can rule out other causes 
of bleeding mistaken by laymen for piles. 

Causes. — Piles are seen chiefly in adults. Overeating and lack 
of exercise favor piles. Constipation is the most common cause in 
bringing pressure on the veins of the lower bowel and preventing the 
proper return of blood. Other causes producing pressure on the veins 



124 GROWTHS AND SWELLINGS 

and favoring the occurrence of piles are pregnancy, tumors of the 
womb, enlarged prostate gland in men. Straining to pass water may 
induce piles. Fatigue, exposure, horseback exercise, or an alcoholic 
debauch may lead to their formation. Certain diseases occasion the 
production of piles, as disorders of the heart, lungs, and liver. 



CHAPTER VIII 
MISCELLANEOUS COMMON SURGICAL DISORDERS 

Bunion. Housemaid's knee. Callus. Corns. Ingrowing- toe nail. Run- 
around. Ganglion. Foreign bodies in the eye, ear, or nose. Swallowing 
foreign bodies. Boils. Carbuncles. Snake bites. Rabies — hydrophobia. 

BUNION— HOUSEMAID'S KNEE 

Bunion is an inflammatory swelling of the bursa, or sac, placed 
so as to cover the outside of the joint of the great toe, where it joins 
the foot. This sac acts normally as a cushion protecting the joint. 
The swelling or bunion may not cause much trouble or, if acutely 
inflamed, it may be hot, red, tender, and very painful. A similar 
swelling from the same cause may sometimes occur on the joint of 
the little toe where it joins the foot. 

Cause of Bunion. — Bunion of the great toe is caused by wearing 
shoes with short, pointed toes which force the great toe toward the 
little toe and thus make the great toe joint more prominent, and so 
more readily injured. 

Symptoms of Bunion. — The bone of the foot entering into the 
great toe joint becomes enlarged and sometimes an abscess forms 
which breaks open and leaves a hole or sinus, discharging much of 
the time. 

Symptoms of Housemaid's Knee. — In housemaid's knee a sim- 
ilar sac, or bursa, normally protecting the kneepan, becomes in- 
flamed in persons who work on their knees, as in scrubbing floors, 
laying carpets, etc. There is a swelling which may be as large as an 
egg covering the lower part of the front of the kneepan. It appears 

125 



126 MISCELLANEOUS COMMON SUBGICAL DISORDERS 

to contain fluid. It may come on slowly with little pain, or it may 
appear suddenly and may be hot, tender, and painful. Occasionally 
an abscess may form. 

Treatment for Bunion and Housemaid's Knee. — The treatment 
for the painful variety of either bunion or housemaid's knee is much 
the same. The patient should rest in bed with the foot raised on a 
pillow and an application of cloths kept constantly wet with ice or 
cold water (or an icebag; or a thick covering of cataplasma kaolini) 
on the bunion or knee until the inflammation has subsided. If the 
trouble is chronic, or the acute inflammation does not abate under 
the treatment advised, the case is one for the surgeon. If there is an 
abscess it must be opened. 

In chronic housemaid's knee the thickened tissues may have to be 
removed, and in chronic bunion the head of the bone of the foot, enter- 
ing into the great toe joint, must be removed to get the toe in proper 
position. In the milder cases of bunion, wearing proper shoes with 
broad toes and with the inner border of the shoe forming a straight 
line from the heel to the toe, and with the heel extended forward on 
the inner side, is to be recommended. Also, when the bunion 
begins to be sore, painting it with tincture of iodin at one sitting, 
until the skin is very dark, will often secure recovery. A light 
splint attached to the inner border of the foot and great toe may 
be applied at night by elastic straps to pull the great toe into line. 

In bunion of the little toe one may use a bunion plaster to relieve 
the pressure of the boot. At night a hot, wet, small towel may be ap- 
plied over the joint Avith a hot water bag to keep it warm, or iodin 
may be painted on the swelling. 



CALLUS AND CORNS 

A callus is a thickening of the outer layer of skin due to con- 
tinuous pressure of the skin between some hard surface and a bone. 
If a callus causes pain, as on the sole of the foot, from pressure on 
the underlying soft parts, it must be removed. 

A corn is a cone-shaped local thickening of the outer layer of skin 



BUNION— HOUSEMAID'S KNEE 127 

of the feet, due to pressure and friction of the shoes, or of opposed 
surfaces of the skin between the toes. A corn or callus is not painful 
in itself but only in bearing down on the sensitive structures beneath. 
Continued irritation of corn or callus may lead to inflammation 
around and beneath with formation of pus. Ordinarily corns are 
tough, yellowish, horny masses but, when moistened by sweat between 
the toes, they are white and are called soft corns. 

Treatment. — Comfortable shoes are the first requisite — well-fit- 
ting and neither tight nor loose. Pressure may be taken from corns 
by the use of corn plasters. To remove corns or callus the foot 
should be soaked for a long time in hot water containing washing 
soda (2 tablespoonfuls to 1 quart of water). Then the hard skin 
should be scraped or pared away with a sharp knife, being very care- 
ful not to cut into the living skin. 

Another useful method consists in painting a corn or callus, night 
and morning for five consecutive days with the following prescrip- 
tion, when both the coating and corn or callus will be removed by 
soaking the same in hot water : — 

Salicylic acid 30 grains 

Tincture of iodin 10 drops 

Extract cannabis indica 10 grains 

Collodion 4 drachms 

When the tissues about a corn become inflamed the patient must 
rest, with the foot elevated and wrapped in a thick layer of absorbent 
cotton saturated with a hot solution of corrosive sublimate (one 
large tablet to the quart of water) and covered with oil silk or rubber 
cloth. Pus must be let out with a knife which has remained in 
boiling water for five minutes. If corns are pared away the foot 
should first be made absolutely clean by soaking in hot soapsuds and 
then by washing in alcohol. The knife or razor should be boiled 
for five minutes or soaked in alcohol ten minutes. The latter method 
does not destroy the knife edge as does boiling. If the knife or skin 
are not clean, and blood is drawn, one may get an infection of the 
part and, in old people and those with feeble circulation, gangrene or 
erysipelas may result. 



128 MISCELLANEOUS COMMON SURGICAL DISORDERS 

Soft corns are removed as above by soaking and scraping, or by 
the use of collodion mixture, applied but two days, owing to the 
more delicate nature of the skin. Then the corn should be dusted with 
a mixture of equal parts of zinc oxid and boric acid, and the toes kept 
apart by pads of absorbent cotton. 



INGROWING TOE NAIL 

Causes. — This is a condition in which the flesh along the edges 
of the great toe nail becomes inflamed, owing to either overgrowth 
of the nail or to pressure of the soft parts against it. Improper foot- 
gear is the common cause — as shoes which are too narrow across the 
toes, or not long enough, or those with high heels which throw the 
toes forward, so as to be compressed by the toe of the boot, especially 
in walking down hill. 

Toe nails should be cut straight across. If the corners are cut 
off the nail has less support from the tougher skin at the end of the 
toe and presses more on the delicate skin at the sides. Also when 
the corners of the nail are cut off the flesh crowds in at the corners 
and, when the nail pushes forward in its growth, it presses on the 
flesh. 

Inflammation from ingrowing toe nail usually arises along the 
outer edge of the nail. The flesh becomes red, tender, painful, and 
swollen, so that it overlaps the nail. After a time "matter" or pus 
forms and finds its way under the nail, and the parts about it ulcerate. 
"Proud flesh" or excessive granulation tissue springs up and imbeds 
the edge of the nail still further. This condition may persist and 
give trouble for months or years, if not properly treated. Nails 
which naturally round upward are more apt to produce trouble 
because the edges are then more likely to grow down into the flesh. 

Treatment. — First cut away the part of the upper of the shoe 
which covers the offending great toe, to remove pressure from it. A 
hot flaxseed poultice applied at night will relieve inflammation and 
pain. Soaking the feet frequently in hot water and practicing un- 
usual cleanliness will hasten recoverv. There are two methods of 



RUNAROUND— WHITLOW OR FELON 129 

curing the trouble; one, to keep the flesh away from the nail, the 
other, to cut the nail away from the flesh. The first is accomplished 
by tucking and crowding a strip of absorbent cotton under the outer 
and front edges of the nail to lift it from the flesh. To further lessen 
the inflammation the cotton may first be soaked in silver nitrate solu- 
tion (ten grains to the ounce of water), or tannic acid or powdered 
alum may be dusted on the flesh before the cotton is tucked between 
it and the nail. This should be repeated every day after soaking the 
foot. 

The other way of keeping the nail away from the inflamed flesh 
is by the use of a thin strip of silver one-quarter of an inch wide. 
This is bent so that it will hook up under the edge of the nail 
and also will encircle the greater part of the under surface of the 
great toe. 

The effect of placing the foot on the ground is to lift the edge of 
the nail from the sore parts by means of the hook. A strand of 
sterile gauze is laid over the raw surface after it is powdered with 
alum and the hook is inserted on top of this; whether absorbent 
cotton or the hook is used they must be kept in place by bandage or 
adhesive plaster. The hook is changed daily and the foot soaked 
and dressed. A few weeks' wear should bring about a cure of the 
condition. 

To prevent the recurrence of ingrowing toe nail proper footgear 
should be worn. The shoes should be broad at the toes, of sufficient 
length, and have low heels. Many operations have been devised to 
cure ingrowing toe nail, but if the flesh is kept away from the edge 
of the nail it may be avoided. If the toe is badly inflamed a 
surgeon's advice should be sought. 



RUNAROUND— WHITLOW OR FELON 

A runaround consists of an inflammation of the soft parts around 
a finger nail. It is more common in the debilitated but may occur in 
any one, owing to the entrance of pus germs through a slight prick or 
abrasion unnoticed at the time. Pus may form in various places : at 



130 MISCELLANEOUS COMMON SURGICAL DISORDERS 

the root of the nail, between the skin and root of the nail, under 
the middle of a nail from a prick between the nail and underlying 
skin, at the tip of the finger, and at the side of the nail from in- 
fection through the abrasion caused by a "hang nail." 

Symptoms of Runaround. — The trouble begins with dusky red- 
ness, slight swelling and pain which is violent, and throbbing, and 
is worse when the hand is held down. Pus forms in one of the 
places noted in about forty-eight hours. The nail is often lost, and 
three months are required to get a complete new nail, and five 
months before the nail is as perfect as before. In mild cases no pus 
forms and the inflammation soon subsides. 

A whitlow or felon is a much more serious trouble than is a run- 
around. It begins generally as a painful swelling of one of the last 
joints of the fingers on the palm side. 

Causes of Felon. — Among the causes are blows, scratches, pricks. 
Often there is no apparent cause, but in some manner the germs gain 
entrance. 

The inflammation may be situated in one of four places : directly 
under the outer layer of the skin (epidermis), in the loose tissue under 
the skin (subcutaneous), in the sheath of the tendon which bends the 
finger, or under the membrane which covers the bone of the finger 
(periosteum). Formerly these were called bone felons, the idea being 
that the inflammation was always on the bone under the periosteum ; 
so that the routine treatment consisted in making a rapid deep cut 
through all the soft tissues directly to the bone. This is bad surgery 
because a deep cut may be unnecessary, but particularly since one 
may spread the inflammation to deeper parts when it is superficial. 

Symptoms of Felon.— The end of the finger becomes hot and 
tense and may throb with excruciating pain. If the inflammation is 
chiefly of the surface there may be redness, or if of the deeper parts, 
the skin may be actually pale. There is usually some fever and the 
pain is made worse by permitting the hand to hang down. If the in- 
flammation is deep in the sheath of the tendons the danger is that it 
may spread along the tendon. In the case of the little finger and 
thumb the inflammation may spread into the palm of the hand and 
from thence into the forearm along the course of the sinews or ten- 



RUNAROUND— WHITLOW OR FELON 131 

dons of the muscles, while this is prevented in the case of the other 
three fingers, the sheath of their tendons being closed at the point 
where the fingers join the palm. 

Death of the bone of the last finger joint, stiffness, crippling, and 
distortion of the hand, after many weeks of pain and multiple in- 
cisions in the hand and arm, or even death from blood poisoning may 
ensue unless prompt surgical treatment is obtained. 

The two conditions of runaround and felon run into each other 
so that a better classification consists in superficial and deep felon. 
In deep felon involving the bone or tendon sheath there is often 
tenderness and swelling of the glands in the armpit of the affected 
side. 

Treatment of Runaround and Felon. — In the beginning of su- 
perficial felon, or runaround with redness and swelling and pain 
about the nail or tip of the finger, the whole of the end of the finger 
below the last joint may be painted once with tincture of iodin and, 
after it is dry, the finger may be wrapped in ten layers of cheesecloth 
wet with a saturated solution of boric acid (as much as warm water 
will dissolve), and the whole covered with a piece of oil silk and 
bandage. If this does not allay the pain and inflammation within 
twenty-four hours from the time of onset, it is a case for the surgeon. 
It may only be necessary to open the epidermis, as in pricking a 
blister, or in trouble at the root or under the nail it may be necessary 
to remove part of the nail. In deep felon, with severe and throb- 
bing pain in the tip of the finger or thumb and perhaps no redness 
whatever, it is unwise to wait and poultice at all, but the patient 
should be given ether and the finger should be opened by a surgeon 
to prevent agonizing, sleepless nights, blood poisoning, and perhaps 
extension of the abscess along the tendon sheath into the hand and 
arm. 

In making the incision the surgeon cuts in on either side of the 
tendon and, if there is no distention of the sheath of the tendon with 
pus, he refrains from opening it but opens the covering membrane 
of the bone to allow of escape of pus there. It may be necessary to 
make several incisions in the finger and hand, if the case is not 
operated early. The same antiseptic poultice of boric acid is applied 



132 MISCELLANEOUS COMMON SUEGICAL DISOEDEES 

to the finger or whole hand, as noted above, and it is changed every 
twenty-four hours to keep it moist. The hand must be placed upon 
a thin board splint, running outside the dressing along the back 
of the hand from the finger tips to within two inches of the elbow, 
and kept in place by adhesive plaster and bandage, and the whole 
held in a sling so that the hand is not allowed to fall down. 

In a case of deep felon, when impossible to secure a surgeon's 
services, it would be best to cut early down to the bone. The cut 
should be made with a very sharp knife (which has been boiled three 
minutes) and the incision should be in the middle of the soft part of 
the last joint of the finger about one-quarter of an inch below the 
joint and extending one-half to three-quarters of an inch toward the 
tip of the finger. There is no danger from too much bleeding. 

The hand should be immediately placed in a warm solution of 
boric acid and, when the bleeding ceases somewhat, the dressing 
advised above should be applied. 



WEEPING SINEW OR GANGLION 

This is a swelling ranging in size from a large bean to an 
inch or more in diameter. It is occasionally seen on the front of 
the wrist or top of the foot, but is more commonly found on the 
back of the wrist. 

Symptoms. — The swelling is painless, hard, and elastic, and not 
tender unless pressed very firmly. It frequently follows some exer- 
tion, the patient feeling something give way. A few days later the 
swelling appears and may gradually increase in size and weaken the 
wrist or make some movements painful, such as playing the piano. 
The overlying skin is not altered in appearance, and freely movable. 
After reaching a certain size the ganglion often ceases to grow, but 
may persist indefinitely ; occasionally a ganglion may disappear spon- 
taneously. A ganglion is a sac attached to the sheath of a tendon, or 
membrane (capsule) enveloping the joint, and contains a clear, 
syrupy fluid or gelatinous substance. Its cavity usually does not com- 
municate with that of the tendon sheath or joint. 



SWALLOWING FOREIGN BODIES 133 

Causes. — The origin of ganglia is somewhat uncertain, but they 
are thought to be due to degeneration of tissue surrounding a tendon 
sheath or joint. 

Treatment. — The simplest treatment consists in suddenly exert- 
ing great pressure on the ganglion with the thumb, or in striking it 
a sharp blow with the back of a book, so that the sac is ruptured and 
the contents escape into the surrounding tissues. The sac may not 
be ruptured, and it usually fills up again even if it is. Another ready 
method is to hold a coin in place (with pressure exerted on the gan- 
glion) by means of a strip of adhesive plaster. After two weeks the 
sac may be obliterated by its walls growing together. A few drops of 
tincture of iodin injected by a doctor into the sac with a hypodermic 
syringe, without drawing any fluid, may cure the ganglion in a week. 
If the ganglion is large, or recurs after simpler methods of treatment 
have been tried, it should be dissected out by a surgeon. 



FOREIGN BODIES IN THE EYE, EAR, AND NOSE 

For methods of treatment of these conditions the reader is re- 
ferred to pages on these subjects. 

SWALLOWING FOREIGN BODIES 

Parents are often greatly alarmed by children swallowing coins, 
pins, safety pins, nails, etc. These may lodge in the gullet, and 
cause pain and difficulty in swallowing, but more often they pass 
through the digestive tract and appear later in the bowel passages. 
Vomiting sometimes continues until the foreign body escapes from 
the bowel, so that it is not necessarily a sign that the coin or other 
substance is still in the stomach. 

Treatment. — Do not give emetics or cathartics as it is dangerous 
to attempt to expel foreign bodies in this way. It is better to give 
the patient as much bulky food as possible, as mush, baked potato, 
bread and milk, with the idea of surrounding the foreign body with 
waste matter and so carrying it along out of the bowel. From eighteen 



13-1 MISCELLANEOUS COMMON SURGICAL DISORDERS 

to thirty-six hours is commonly required for substances to pass 
through the stomach and bowels. After this time a dose of fluid- 
extract of caseara sagrada or other mild laxative may be given. 

Usually no harm results from the swallowing of foreign bodies by 
children or adults. Sometimes they may lodge just inside the exit 
of the bowel and may be removed by the finger. 



BOILS 

A boil is a circumscribed inflammatory process caused by the 
entrance of pus-producing germs into the skin, either through the 
pores (the mouths of the sweat glands) or along the shafts of the 
hair, and in this way invading the glands which secrete a greasy 
material (sebaceous glands). In either case the pus germs set up an 
inflammation of the sweat or sebaceous glands and the surrounding 
structures of the skin, and a small, red, itching pimple results. 

Rarely, after a few days, does the redness and swelling disappear, 
and the pus, if any, dry and the whole process subside. This is 
called a blind boil. But usually the boil increases in size for several 
days, until it may be as large as a pigeon's egg. It assumes a bright- 
red, sharply defined, rounded shape, with a conical point, and is at 
first hard and then softens, as pus or "matter" forms. There is 
severe pain of a throbbing, boring character, which is worse at night, 
and destroys the patient's sleep and appetite; there may be some 
fever. The glands in the neighborhood may be enlarged and tender, 
owing to some of the pus germs escaping from the boil and lodging 
in the glands. 

If the boil is not lanced, it reaches its full development in seven 
to ten days with the formation of a central core of dead tissue and 
some pus, which gives to the center of the boil a whitish or yellowish- 
brown appearance. The boil then breaks down spontaneously in one 
or more places (usually only one) and discharges some pus, and, 
with a little gentle pressure, also the white, central core of dead 
tissue. The remaining wound closes in and heals in a week or two. 
Boils occur singly or in numbers, and sometimes in successive crops. 



BOILS 135 

When this happens it is because the pus germs from the previous boils 
have invaded fresh areas of skin. 

Causes. — Boils are thus contagious, the pus germs being com- 
municated to new points on the patient's skin, or to that of another 
person. Local irritation of the skin, from whatever cause, enables the 
germs to grow more readily. The existence of skin diseases, as 
eczema ("salt rheum"), prickly heat, and other sources of itching and 
scratching, is conducive to boils, as the pus germs contained in ordi- 
nary dirt are rubbed into the irritated skin. Whenever the skin is 
chafed by rough clothing, as about the wrists and neck by frayed 
collars and sweaters, etc., boils are likely to occur. Also when the 
face and neck are handled by barbers with dirty hands or instru- 
ments, a fruitful source is provided for their invasion. While boils 
are always the result of pus gaining entrance to the skin glands, and, 
therefore, strictly due to local causes, yet they are more prone to 
occur when the body is weakened and unable to cope with germs which 
might do no harm under other circumstances. 

The conditions favoring the occurrence of boils are: an im- 
poverished state of the blood, errors of diet and indigestion, over- 
work, dissipation, and certain diseases, as typhoid fever, diabetes, 
and smallpox. Boils are thought to occur more frequently in per- 
sons with rough skin and with a vigorous growth of dark hair. They 
may be situated on any part of the body, but certain localities are 
commonly attacked, as the scalp, the eyelids, cheeks, neck, arm- 
pits, back, and buttocks. Boys and young men are generally the 
sufferers. 

Treatment. — The importance of cleanliness cannot be overesti- 
mated in the care of boils if we keep their cause in mind. Dirty 
underclothes or fingers used in squeezing or otherwise handling the 
boil, may carry the trouble to fresh parts. Any sort of local irrita- 
tion should be removed; also all articles of clothing which have 
come in contact with the boils should not be worn until they have 
been washed in boiling water. In boils on the neck a soft collar 
should be worn. There is no single remedy of much value for the cure 
of boils, although taking a Fleischmann's yeast cake once daily, by 
crumbling and stirring it in water, is often a good means of arresting 



136 MISCELLANEOUS COMMON SURGICAL DISORDERS 

the trouble. Also pills of calcium sulphid (each one-tenth grain) 
are commonly prescribed by physicians, every three hours. 

The most rational measure consists in removing the general causes, 
as noted above, if this is possible. When the patient is thin and 
poorly nourished, food and cod-liver oil should be given ; and if the 
lips and skin are pale, iron arsenate pills (one-sixteenth grain each) 
should be taken three times daily for several weeks. 

The local treatment is by far the most important. A boil may 
sometimes be arrested by painting it with tincture of iodin until the 
boil is almost black, or with a very heavy coating of collodion. As 
soon as the boil softens in the middle a toothpick should be dipped in 
pure carbolic acid and thrust for one-quarter to one-half an inch into 
the center of the boil. This is but slightly painful and is wonder- 
fully curative. 

The boil should then be kept smeared with carbolized vaselin or 
the following ointment, and covered with sterile gauze held in place 
by bandage or strips of surgeon's adhesive plaster. 

Formula for Oixtmext 

Precipitated sulphur 1 drachm 

Boric acid 1 drachm 

Carbolized vaselin 1 ounce 

Mix and apply externally. 

To prevent a crop of boils, the skin all about the boil should be 
washed with soap and water and then with a mixture of two parts 
alcohol and one part water. In boils on the neck this should be done 
over the neck and upper part of the back daily for some weeks after 
the last boil has disappeared. 

Poultices are not advisable, as they favor the formation of new 
boils, but if very painful a boil may be covered by eight or ten layers 
of sterile gauze soaked in a saturated boric acid solution and covered 
with oil silk and bandage. 

L^nless the boil is far advanced before treatment is begun and 
contains a good deal of pus it is not necessary to use the knife. This 
is especially so if the carbolic acid has been used early. If the 
boil must be opened it should be thoroughly cleaned with hot water, 



CARBUNCLES 137 

soap, alcohol ; and a sharp knife, which has been boiled in water for 
five minutes, should be inserted, point first, into the center of the 
boil, far enough to liberate the pus and dead tissue. By this means 
healing is much more rapid than by nature's unassisted methods. In 
case boils keep recurring the best treatment consists in the injection 
of a vaccine made of killed pus germs. 

Such treatment can only be given by a doctor. At the same time 
he will examine the urine to see if there is diabetes, because this 
disease often leads to the occurrence of boils. 



CARBUNCLES 

A carbuncle is similar to a boil in its causation and structure but 
is usually a much more serious matter, having a tendency to spread 
laterally and involve the deeper layers of the skin. It differs from 
a boil in being much larger, in having a rounded or flat top instead of 
the conical shape of boils, and especially in having numerous, sieve- 
like openings, in the occurrence of death of the skin over the top of 
the carbuncle, and in being accompanied by intense pain and high 
fever. 

It is commonly a disease of old persons, those prematurely old or 
debilitated or suffering from diabetes or Bright's disease, and occurs 
most frequently on the neck, back, or buttocks. It is particularly 
dangerous when attacking the back of the neck, upper lip, or abdo- 
men. 

Symptoms. — Carbuncle often begins with a chill and fever. It 
starts as a pimple, and rapidly increases in size, forming a hot, dusky 
red, rounded lump which may grow until it is from three to six 
inches in diameter. Occasionally it runs a mild course, remains 
small, and begins to discharge pus and dead tissue at the end of a 
week, and heals rapidly. More commonly the pain soon becomes in- 
tense, of a burning, throbbing character, and the carbuncle continues 
to enlarge for a week or ten days, when it softens and breaks open at 
various points discharging shreds of dead tissue and pus. The skin 
over the whole top of the carbuncle dies and sloughs away, leaving 



138 MISCELLANEOUS COMMON SUEGICAL DISORDERS 

an angry-looking excavation or craterlike ulcer. This slowly heals 
from the edges and bottom, so that the whole period of healing occu- 
pies from a week to two, or even six months. 

The danger depends largely upon blood poisoning, and also upon 
pain, continuous fever, and exhaustion which follow it. Sweating 
and fever, higher at night, are the more prominent signs of blood 
poisoning. 

Treatment. — Carbuncle demands the earliest treatment by a 
skilled surgeon, as it is only by the complete removal of the carbuncle, 
in the same way that one would remove the core of an apple, or, in 
more advanced cases the making of deep cross incisions into the 
carbuncle and cutting away all diseased tissue, that the best results 
are accomplished. However, when a surgeon cannot be obtained, the 
patient's strength should be sustained by feeding every two hours 
with beef tea, milk, and raw eggs, and with wine or alcoholic liquors. 
Three two-grain quinin pills and ten drops of the tincture of the 
chlorid of iron in water should be given three times daily. 

The local treatment consists in applying large hot, fresh flaxseed 
poultices frequently, with the removal of all dead tissue with scissors 
previously boiled in water for ten minutes. When the pain is not 
unbearable, dressings made by soaking thick sheets of gauze or absor- 
bent cotton in hot solution of corrosive sublimate (1 part to 5000 
parts of water) should be applied and covered by oil silk or rubber 
cloth and bandage. They are far preferable to poultices, being better 
germ destroyers. When the dead tissue comes away and the car- 
buncle presents a red, raw surface, it should be washed twice a day 
in corrosive sublimate solution (1 part to 3000 parts of water), 
dusted with pure boric acid, and covered with clean, dry absorbent 
cotton and bandage. 

SNAKE BITES 

Various Species of Snakes. — There are many different species 
of poisonous snakes in the United States. The more common are 
the rattlesnakes, the water moccasin, the copperhead, the harlequin 
and coral snake. These, and the venomous snakes of South America, 



SNAKE BITES 139 

all belong to the rattlesnake family (Crotalinae), a subfamily of 
the viper family (Viperidae). 

All our venomous snakes have certain characteristics by which 
they may be distinguished from their harmless brethren. The head 
is generally broad and flat and of a triangular shape, the wide, heavy 
jaws tapering to a point at the lips. There is a depression or pit on 
the upper lip, between the nostril and eye' — hence the name "pit 
vipers" given to poisonous snakes. The pupil of the eye is long and 
vertical, of an oval or elliptical shape. 

Venomous snakes are thicker in proportion to their length than 
harmless snakes, the surface of their bodies is rougher, and their 
tails are blunt or club-shaped. Conversely, harmless snakes possess 
long narrow heads, the pupils of their eyes are round, not vertical, 
slits, and their bodies are not thick for their length, but long and 
slim with pointed tails. The bite of vipers of all kinds is much more 
poisonous in tropical regions ; in the North fatal snake bite is a rare 
occurrence. 

In Cuba and Porto Rico there is a viper called Juba, or Boaquira, 
which is a counterpart of the Northern rattlesnake, and the most 
poisonous of the many species in that region. Among venomous 
species of the Philippines are two boas and also a viper from nine 
to ten feet long, which rarely pursues and attacks man. This snake 
is easily killed by a blow on the neck. Another small viper with 
a club-shaped tail, inhabiting these islands, is nocturnal in its habits, 
and may get into boots at night. Boots, therefore, should always 
be inspected before one puts them on in the morning. 

In South America are found the rattlesnake, in Brazil and North 
Argentina the bushmaster, in Venezuela, various species of the genus 
Lachesis, of which the fer de lance is best known, and is native to 
the West Indies as well. There are small poisonous vipers in differ- 
ent parts of Europe, and it is said that ten per cent, of persons 
bitten by them die. In India, China, and South Asia are the cobra, 
krait and poisonous vipers ; in Africa the cobra and vipers ; in Aus- 
tralia and Tasmania the copperhead, tiger snake, death adder, and 
brown and black venomous snakes — all of them members of the 
cobra family. 



140 MISCELLANEOUS COMMON SUBGICAL DISORDERS 

There are many poisonous lizards, although in the United States 
the only dangerous one is the gila monster. 

The poisonous snakes are broadly divided into the colubrine and 
viperine groups, because of natural differences in their structure and 
effects of their poisons. Snake venom contains a number of poison- 
ous substances (toxalbumins) . some of which predominate in the 
viper family and others in the cobra group. Thus neurotoxin is the 
chief poisonous substance in the cobra venom and paralyzes the whole 
nervous system, especially that part sustaining the respiration. Other 
substances more particularly in the venom (hemorrhagin and hemoly- 
sin), of the rattlesnake family, favor internal bleeding, by destroying 
the walls of the blood vessels and making the blood more fluid or 
breaking up the red blood cells. These substances cause the discolora- 
tion of the skin, and perhaps gangrene of the bitten part, seen in 
rattlesnake bites. Such is the basis for the different groups of symp- 
toms seen in the bites of viperines and colubrines. 

If there is a doubt whether a snake is poisonous, the neck may be 
pressed down against the ground between the jaws of a forked stick 
and the poison fangs looked for without danger. These hang directly 
down from the front part of the upper jaw, or are thrust horizontally 
forward just in front of the upper lip, and may drip saliva and venom. 

Symptoms of Bites by Viperines (Rattlesnake Family). — At 
first there is severe pain in the bite, which increases, together with 
swelling and purple discoloration. Besides there is great prostration, 
staggering gait, nausea or vomiting, cold sweats, rapid, feeble pulse, 
labored breathing, and perhaps drowsiness and stupor. Death may 
occur in this stage within twelve hours, or the swelling and dis- 
coloration may extend to the body, and symptoms of blood poisoning. 
with fever and great weakness, may ensue. If the patient survives 
this he may die weeks later from gangrene and infection in the bitten 
part. Recovery is more often rapid after a few hours and, in many 
sections of this country, death from rattlesnake bite is very rare. In 
Europe the effects of the viper bites are similar to the milder forms 
of rattlesnake bite. 

Symptoms of Bites by Colubrines {Cobra, Era it and Austra- 
lian Venomous Snakes). — The pain, swelling, and discoloration about 



SNAKE BITES 141 

the bite are not so marked. But in half an hour or so after the acci- 
dent the effects of the paralyzing substance (neurotoxin) become 
evident. The patient feels drowsy, acts as if intoxicated, and be- 
comes so weak he cannot stand. There is a profuse flow of saliva 
and the tongue and throat are so paralyzed that the subject may not 
be able to speak or swallow. Then paralysis becomes general, the 
patient lies on his back unable to move, the breathing becomes slower 
and weaker and finally stops, with or without convulsions. 

Treatment. — Tie a large cord, a bandage, or a strip of clothing, 
tightly about the limb. If the bite is in the leg, tie above the knee ; 
if in the arm, tie above the elbow. This should be done at once. The 
cord should be tied tightly and then made still tighter by passing a 
stick under it and twisting it up. 

Now the poison is kept from being absorbed into the general cir- 
culation. The next consideration is the getting rid of it. A sharp 
clean knife should be used to remove an oval piece of skin about two 
inches long and including the site of the bite. If an attendant or the 
patient' are unable to accomplish this, a cut, running lengthwise with 
the limb and about half an inch deep, should be made directly 
through the bite and for an inch either side. 

The tissues should then be squeezed all about the wound so as 
to promote the escape of blood and poison with it. The cord should 
be loosened about the limb at the end of fifteen minutes, and after 
two minutes it should be tightened again, and allowed to remain 
fifteen minutes longer. The wound should not be sucked. When the 
wound has bled freely it should be washed out with a solution of 
permanganate of potash (as much as water will dissolve). 

One may inject permanganate of potash with a hypodermic 
syringe, a whole syringeful of a solution (grains 5 to 1 ounce of 
water) in two or three places as near the exact site of the bite as 
possible. The best way consists in cutting out the area containing 
the bite and then washing with the permanganate solution but, when 
one has not the nerve to do this, the next best treatment is to cut 
deep into the wound, encourage bleeding, and then inject the perman- 
ganate (with the hypodermic syringe) and wash out the wound with 
it also. 



142 MISCELLANEOUS COMMON SURGICAL DISORDERS 

Three tea spoonfuls of whisky with the same amount of water 
should be given every thirty minutes, and injections with a hypo- 
dermic syringe of one-thirtieth of a grain of strychnin sulphate 
should be made every thirty minutes, for three or four doses, if the 
pulse is weak. Giving large amounts of whisky is harmful and also 
walking the patient around if drowsy — his strength should be saved. 

In addition one may inject a serum for snake bite ; in order to be 
efficient one should use a different serum for every variety of snake. 
There is an antivenin made by Flexner and Xoguchi which is most 
valuable in rattlesnake bite. The whole amount supplied should be 
injected into a vein and at once after the bite, before symptoms are 
manifest, to secure the best result. 

There is no serum which is efficient in the treatment of bites of 
all kinds of snakes. The serum used is that of horses which have 
received increasing doses of snake venom until an antitoxin is 
formed in their blood. If cobra venom is injected then the horse 
serum contains an antitoxin against this snake, but not against rattle- 
snake poison. It has not been found possible to inject venoms of 
all the poisonous snakes into a horse and to secure a serum which 
will also antagonize all. 

Usually it is only the young, old, and weak who succumb to snake 
bites. 

RABIES— HYDROPHOBIA 

Bites of animals should be treated like punctured wounds, unless 
there is danger of hydrophobia. There is no danger of hydrophobia 
from the bite of an animal unless it is affected with rabies. 

Eabies in animals is the same disease as hydrophobia in man. 
Kabies is due to a special genu which is transmitted from the saliva 
of the rabid dos; to other animals or man bv biting. 

Many writers have tried to prove that hydrophobia is an imagi- 
nary disease, but the disease is quite common in dogs and as well 
recognized in man or animals as any disease known, and is invariably 
fatal in either. 

Symptoms of Rabies. — After a dog is bitten, several days or 



RABIES— HYDROPHOBIA 143 

months — twenty-five days on the average — elapse before the disease 
manifests itself. Then the disposition of the animal is altered ; he 
licks and swallows all kinds of objects and often vomits. After a 
few days the animal is apt to leave home and travel great distances, 
biting everything in his way, and may return home to die. The 
voice is hoarse, the tail droops and the head is depressed, with staring, 
glazed, bloodshot eyes ; the animal is insensible to pain, persons, or 
surroundings ; the gait is unsteady and the animal becomes emaciated 
and repulsive. In the last stage, and sometimes at the beginning, 
there is a paralysis of the lower jaw and perhaps of the hind limbs; 
the lower jaw drops, the tongue is dry, and covered with stringy 
mucus and the animal can neither swallow, howl nor bite. Death 
is invariable, usually in four days. The animal has no fear of 
water at any time, but in the later stages he tries to swallow water 
but cannot, on account of paralysis of the throat, and for this reason 
he may appear to have a bone in his throat. 

When a person is bitten it is imperative to know whether the 
biting animal was mad (rabid). Therefore, the animal should be 
kept alive and shut up so that he can be watched ; if he is alive 
and well after two weeks he has not rabies. If a suspected mad 
animal has been killed or dies, a correct diagnosis can usually be 
made in the laboratory, so that it is important that the body always 
be sent to a trained pathologist. 

Treatment in Man. — If there is doubt whether an animal has 
rabies, and he has bitten persons or animals and has been killed or 
run away and the body cannot be examined by a trained pathologist, 
the bitten person should always take the Pasteur treatment. This 
may now be given by any doctor, is comparatively harmless and will 
surely prevent rabies when taken within a week or so after receiving 
the bite. In man the disease develops usually in about thirty days 
after the bite, but this period may vary from fifteen days to six or 
more months. 

If the bite is on a limb tie tightly a cord, bandage, or piece of 
clothing about the bitten limb above the knee or elbow, and twist it 
tighter with a stick. If the wound is large enough, wash out with 
water and a syringe and then dip a stick into pure carbolic acid or 



m MISCELLANEOUS COMMON SURGICAL DISOBDEES 

tincture of iodin and swab the wound with it, or cauterize the wound 
by thrusting a red hot nail or poker into it. Better still, cut out 
the rlesh. including the bite, with a sharp knife. One should natu- 
rally have good reason to suspect the biting animal was actually mad 
before adopting such caustic methods. Finally, if there is any doubt 
concerning the madness of an animal who has bitten a person the 
latter should always have the Pasteur treatment. The percentage 
of persons not receiving the Pasteur treatment who develop hydro- 
phobia after being bitten by rabid animals varies greatly (average 
said to be fourteen per cent. ) with the site of the bite. Bites on un- 
clothed parts of the body are much more dangerous. 



CHAPTEE IX 
SKIN DISEASES— BITES AND STINGS OF INSECTS 

Itching. Chafing. Hives. Pimples. Blackheads. Cold Sore. Prickly 
Heat. Bingworm. Freckles. Tan. Ivy poison. Warts. Baldness. 
The itch. Callus and Cracks. Eczema. Erysipelas. Bites of Mosqui- 
toes, bees, wasps, hornets, wood ticks, lice, fleas, bed bugs, flies, scor- 
pions, centipedes, spiders. 



SKIN DISEASES 

No attempt will be made to give an extended account of skin 
diseases, but a few of the more common disorders which can be read- 
ily recognized by the layman will be given special attention. Al- 
though these cutaneous troubles are often of so trivial a nature that 
a physician's assistance is unsought, yet the annoyance is sufficient 
to make it worth while for the patient to inform himself about the 
ailment. Then the affections are so frequent that they may occur 
where it is impossible to procure medical aid. Whenever an erup- 
tion of the skin is accompanied by fever, sore throat, headache, pains 
in back and limbs, vomiting, or general illness, one of the serious, 
contagious, eruptive diseases should be suspected, particularly in 
children, and the patient must be removed from contact with others, 
kept in isolation, and a physician immediately summoned. 

ITCHING 

(Pruritis) 

Itching is not a distinct disease by itself, but a symptom or sign 
of other skin or general disorders. Occasionally it must be treated as 
if it were a separate disease, as when it occurs about the entrance to 

145 



146 SKIN DISEASES— BITES AXD STIXGS OF INSECTS 

the bowel (anus), or to the external female sexual parts (vulva), or 
attacks the skin generally, and is not accompanied by any skin erup- 
tion except that caused by scratching, the cause being unascertainable. 

Causes. — Itching, without apparent cause, may be due to para- 
sites, as lice and fleas — and this must always be kept in mind, al- 
though debilitated states of the body and certain diseases, as gout 
and diabetes, are sometimes the source. Commonly, itching is caused 
by one of the many recognized skin diseases, and is accompanied by 
an eruption characteristic of the particular disorder existing ; special 
treatment by an expert, directed to remedy this condition, is the only 
reasonable way to relieve the itching and cure the trouble. 

Treatment. —It may not. however, be improper to suggest means 
to relieve such a source of suffering as is itching, although unscien- 
tific, with the clear understanding that a cure cannot always be ex- 
pected, but relief may be obtained until proper medical advice can 
be secured. The treatment to be given will be appropriate for itching 
due to any cause, with or without existing eruption on the skin, unless 
otherwise specified. If one remedy is unsuccessful, try others. 

For itching afflicting a considerable portion of the skin, baths are 
peculiarly effective. Cold shower baths twice daily, or swimming in 
cold water at the proper time of year, may be tried, but tepid or luke- 
warm baths are generally more effective. The addition of saleratus 
or baking soda, one to two pounds to the bath, is valuable, or bran 
water obtained by boiling bran tied in a bag in water, and adding the 
resulting solution to the bath. Even more efficient is a bath made 
by dissolving half a cupful of boiled starch and one tablespoonful of 
washing or baking soda in four gallons of warm water. The tepid 
baths should be as prolonged as possible, without chilling the patient. 
The bran water, or starch water, may be put in a basin and sopped on 
the patient with a soft linen or cotton cloth and allowed to evaporate 
from the skin, without rubbing, but while the skin is still moist a 
powder composed of boric acid, one part, and pulverized starch, four 
parts, should be dusted on the itching area. 

Household remedies of value include saleratus or baking soda 
(one teaspoonful to the pint of cold water), or equal parts of alcohol 
or vinegar and water, which are used to bathe the itching parts and 



SKIN DISEASES 147 

permitted to dry on them. Calamin lotion is also a serviceable prep- 
aration when there is redness and swelling of the skin. 

When the itching is confined to small areas, or due to a pimply 
or scaly eruption on the skin, the following ointments may be tried : 
a mixture of tar ointment and zinc ointment (two drachms each), 
with four drachms of cold cream; or flowers of sulphur, one part, 
and lard, twelve parts, or resinol ointment. 

CHAFING AND CHAPPING 

Chafing occurs when two opposing skin surfaces rub together and 
are irritated by sweat, as in the armpits, under the breasts, and be- 
neath overlapping parts of the belly of fat people, and between the 
thighs and buttocks. The same result is caused by the irritation in- 
duced by discharges constantly running over the skin, as that seen 
in infants, due to "the presence of urine and bowel discharges, and 
that irritation which arises from saliva when the lips are frequently 
licked. The latter condition of the lips is commonly called chap- 
ping, but it is proper to consider chafing and chapping together as 
the morbid state of the skin, and the treatment is the same in both. 

Chafing occurs more often in hot weather and after violent exer- 
cise, as rowing, riding, or running, and is aggravated by the friction 
of clothing or of tight boots. It may, on the other hand, appear in 
persons who sit a great deal, owing to constant pressure and friction 
in one place. The parts are hot, red, and tender, and emit a dis- 
agreeable odor when secretions are retained. The skin becomes sod- 
den by retained sweat, and may crack and bleed. The same redness 
and tenderness are seen in chapping of the face and lips, and crack- 
ing of the lips is frequent. 

Treatment. —In chafing, the first requisite is to remove the cause, 
and then thoroughly wash the part with soap and water. Then a 
saturated solution of boric acid in water should be applied with a 
soft cloth, and the parts dusted with a mixture of boric acid and 
powdered starch, equal parts, three times daily; or calamin lotion 
is an excellent preparation. 

If the lips are cracked, painting the cracks with compound tinc- 
ture of benzoin three times dailv, with a camel's-hair brush, will be 



148 SKIN DISEASES— BITES AXD STINGS OF IXSECTS 

found curative. Chapping of the lips is prevented by the use of cold 
cream. 

HIVES— NETTLERASH 

(Urticaria) 

Symptoms. — Hives is characterized by the sudden appearance 
of hard round or oval lumps in the skin, from the size of a flattened 
pea to (rarely) that of a silver dollar, of a pink or white color, or 
white in the center, and surrounded by a red blush. The rash is 
accompanied by much itching, burning, or tingling, especially at 
night when the clothes are removed. The peculiarity of this eruption 
is the suddenness with which the rash appears and disappears; the 
itching, the whitish or red lumps, the fact that the eruption affects 
any part of the body and does not run together, are also character- 
istic. Scratching of the skin often brings out the lumps in a few min- 
utes. The swellings may last a few minutes or hours, and suddenly 
disappear to reappear in some other place. The whole trouble usu- 
ally continues only a few days, although at times it becomes a chronic 
affection. 

Scratching alters the character of the eruption, and causes red, 
raw marks and crusts, but the ordinary swellings can be seen usually 
in some part of the body. Rarely, the eruption comes in the throat 
and leads to sudden and sometimes dangerous swellings, so that suf- 
focation has ensued. Fever, sore throat, backache, and headache, 
which are common in the contagious eruptive disorders, as measles, 
scarlet fever, etc., are not present with hives. 

Causes. — Indigestion is the most frequent cause. Certain arti- 
cles of diet are almost sure to bring on an attack of hives in suscep- 
tible persons; these include shellfish, clams, lobsters, crabs, rarely 
oysters ; also oatmeal, buckwheat cakes, cheese, pork, sausages, pickles, 
and mushrooms ; acid fruits, particularly strawberries, but sometimes 
raspberries and peaches. Xettlerash is common in children, and may 
follow any local irritation of the skin caused by rough clothes, bites 
of mosquitoes and fleas, and the stings of jellyfish, Portuguese man- 
of-war, and nettles. Xettlerash is also favored by certain disorders 
as gout, rheumatism, malaria, and is common in pregnancy. 



SKIN DISEASES 149 

Treatment. — Remove any source of irritation in the digestive 
canal, or externally, and employ a simple diet for a few days, as 
bread and milk. 

A heaping tablespoonful of Epsom salts in a whole glass of water 
before breakfast is suitable for an adult, or any other active cathartic 
may be taken. For children a half to a teaspoonful of aromatic fluid- 
extract of cascara sagrada is a pleasant and active cathartic, but in 
severe cases from two to four teaspoonfuls of castor oil are more ef- 
fective. 

Locally we use, as domestic remedies, a saturated solution of bak- 
ing soda (or saleratus) in water, or equal parts of alcohol or vinegar 
and water to relieve the itching. The bath containing soda and starch 
(see Itching) is the most useful treatment when the nettlerash is 
general. The following lotion is one of the best applications which 
can be employed for this disorder. It should be sopped on fre- 
quently with a soft cloth and allowed to dry on the skin. 

Formula for Lotion 

Acid carbolic 1 drachm 

Glycerin 1 drachm 

Alcohol 1 ounce 

Water , 7 ounces 

Mix and apply externally to relieve itching. 

PIMPLES— BLACKHEADS 

(Acne) 

Pimples. — This eruption is situated chiefly on the face, but often 
on the back, shoulders, and chest as well. It is a disorder which is 
seen mostly in young men and women at about the age of puberty. 

It consists of conical elevations of the skin, from a pinhead to 
a pea in size, often reddened and tender on pressure and having a 
tendency to form matter or pus, as shown by a yellow spot in the cen- 
ter of the pimple. After three to ten days the matter is discharged, 
but red elevations remain, which later become brown and disappear, 
except in rare cases, without scarring. 

Blackheads. — Blackheads appear as slightly elevated black 



150 SKIN DISEASES— BITES AND STINGS OF INSECTS 

points no bigger than the head or point of a pin. sometimes having 
a yellowish tint from which a little, thin, wonnlike mass may be 
pressed. Pimples and blackheads are both due to inflammation abont 
the glands of the skin which secrete oily material : the months of 
the glands become plugged, thus retaining the oily secretion and caus- 
ing blackheads. 

Causes. — The true cause of the skin inflammation or acne is un- 
certain. It may be the result of an irritant eliminated by the skin 
from the blood. It is more commonly believed to be due to a special 
germ found in the pores of the skin. Then as the glands also are 
invaded by the gemis producing pus. we have a pimple, which usu- 
ally results in the formation of matter as described above. Consti- 
pation and indigestion favor the occurrence of pimples and black- 
heads ; also a poor state of the blood, or anemia. 

Treatment. — Tea. coffee, tobacco, beer, and alcohol should be 
avoided, together with sweets, pastry, cake. veal. pork, fats, and 
cheese. The diet should be simple, consisting of cereals (except oat- 
meal ) with eggs, bread and butter, and fruit for breakfast and lunch, 
and at dinner, meat or white fish, vegetables, lettuce salad with 
Trench dressing and fruit or simple pudding. A cup of hot water 
should be taken before meals, and a glass of cold water at meals and 
two hours after, and at bedtime. At least one hour daily of out- 
door exercise is requisite in games, riding bicycling, or walking. 

A daily bath followed by vigorous friction with a rough towel 
is important in all cases to stimulate the skin. The bowels must be 
moved daily by some proper cathartic, as cascara tablets containing 
two grains each of the extract. The dose is one to two tablets at 
night. 

The blackheads should be squeezed out with a watch key, or with 
an instrument made for the purpose — not finger nails — and pimples 
containing matter must be emptied after being pricked with a needle 
(which has been passed through a fiame to kill germs on it). If the 
inflammation is not marked one should thoroughly massage the skin 
of the forehead, nose and cheeks, pinching it so as to squeeze out 
the contents of the pores. This should be done at bedtime. Then 
bathe the face well with hot water and apply the following lotion : — 



SKIN DISEASES 151 

Precipitated sulphur 1 drachm 

Zinc sulphate 1 

Sulphuretted potassium 1 

Water 4 ounces 

Mix, shake, and apply to skin. 

If there is redness of the skin and irritation associated with 
pimples, it is sufficient to bathe the skin with very hot water and 
green soap three times daily, and apply calamin lotion at night. 
In other cases, when the skin is not sensitive, and zinc or mercury 
has not been used, the employment of sulphur soap and hot water at 
bedtime, allowing the suds to dry and remain on the face during the 
night, is recommended. An ointment consisting of one-half dram 
of precipitated sulphur with one-half ounce each of powdered starch 
and vaselin applied each night, and hot water used on the face three 
times daily are also efficacious. 

Among recent treatments that with vaccine, made of the killed 
germs responsible for the trouble, is sometimes very successful, 
especially when pus formation is frequent. The specialist also some- 
times finds the x-ray of value. The disease requires a long time 
for cure but commonly disappears after early adult life. 

The services of a specialist are almost always required to ob- 
tain good results, and even then much perseverance is needed by 
both doctor and patient. 

COLD SORE— FEVER BLISTER 

(Herpes) 

Cold sores occur usually about the lips or at the angles of the 
mouth, although they may appear anywhere on the face. 

Cold sore has a round, oval, or irregular outline from the size of 
a pea to that of a quarter of a dollar, and is seen as a slightly raised 
patch on the skin on which is a group of very minute blisters, three 
to twelve in number. Cold sore may be single or multiple, and near 
together or widely separated on the face. Having first the appear- 
ance of a red patch, it later becomes covered with a brown crust from 
the drying of the contents of the tiny blisters. Cold sore often gives 
rise to burning, itching, or tingling, the disfigurement usually caus- 



152 SKIN DISEASES— BITES AND STINGS OF INSECTS 

ing more annoyance, however, than pain. The duration of the trouble 
is from four to twelve days. 

Causes. — Cold sores are commonly induced by indigestion and 
fevers, and also are occasioned by local irritation of any sort, as from 
nasal discharge accompanying cold in the head (from which the name 
is derived), by the irritation produced by a pipestem or cigar, and 
by rubbing the skin. They are usually caused by the germ of pneu- 
monia. Fever blisters often appear in women about the time of men- 
struation. They also are common from exposure to the sun, espe- 
cially on the water. 

Treatment. — Picking and scratching are very harmful, and cigar 
or pipe smoking must be stopped. Apply spirit of camphor fre- 
quently, and also if there is much itching or burning, sop the erup- 
tion with calamin lotion ; this will relieve the discomfort. 

Formula for Calamin Lotion 

Zinc oxid 1 drachm 

Calamin 1 drachm 

Glycerin 3^ ounce 

Lime water 1 ounce 

Eose water %y 2 ounces 

Mix and apply externally. 

Shake before using. 

When the trouble occurs at the corners of the mouth or when 
there is any cracking of the lips, painting the parts with compound 
tincture of benzoin three times daily is advisable. 

PRICKLY HEAT 

{Miliaria) 

This is a common eruption of adults in hot weather, and very 
frequently attacks children. 

Symptoms. — It consists of a fine, pointed, red rash, or minute 
blisters, and occurs on parts of the body covered by clothing, more 
often on the chest. The eruption is caused by much sweating, leading 
to congestion and swelling of the sweat glands. Burning, stinging 
and itching accompany the disorder. 



SKIN DISEASES 153 

The condition must be distinguished from the contagious skin 
eruptions. In the latter there are fever, sore throat, backache, head- 
ache, and general sickness, while in prickly heat there is no general 
disturbance of the system, or fever, unless the eruption comes out in 
the course of fevers, when it is of no significance except as one of the 
symptoms of fever. 

Treatment.— The treatment of prickly heat, occurring in hot 
weather, consists in avoiding heat as much as possible, the wearing 
of light clothing day and night, and sponging the surface with cold 
water, and then dusting it with some simple powder, as starch or flour, 
or better, borated talcum. To relieve the itching, sponging with 
limewater or a saturated solution of baking soda (as much as will 
dissolve in water), or bran baths, made by tying one pound of bran 
in a towel which is allowed to soak in the bath, are all good remedies. 
The use of a toilet talcum powder over the skin after one of these 
preparations is also advisable. 

RINGWORM OF THE BODY— RINGWORM OF THE SCALP 

Causes. — This skin disease is caused by a vegetable fungus and 
not by a worm as the name suggests. The disease on the body and 
scalp is caused by the same parasite, but ringworm of the body may 
attack adults as well as children, and is readily cured ; ringworm of 
the scalp is a disease confined to children, and is difficult of cure. 

Ringworm is contagious and may be acquired from children with 
the disease, and therefore patients suffering from it should not be 
sent to school, and should wear a skull cap and have brush, comb, 
towels, and wash cloths reserved for their personal use. Children 
frequently contract the disease from fondling and handling cats and 
dogs. 

Symptoms. — On the body, ringworm attacks the face, neck, and 
hands. It appears first as small, red, scaly spots which may spread 
into an irregularly circular patch as large as a dollar with a red 
ring of small, scaly pimples on the outside, while the center exhibits 
healthy skin, or sometimes is red and thickened. There may be sev- 
eral patches of ringworm near each other and they may run together, 
or there may be only one patch of the disease. Ringworm of the 



154 SKIN DISEASES— BITES AND STINGS OF INSECTS 

scalp occurs as a circular, scaly, partially bald patch from the size 
of a nickel to that of a silver dollar, of a dusty-gray or pale-red color 
on which there are stubs of broken hairs with split ends pointing 
in different directions, and readily broken off in the attempt to pull 
them out. The disease in this locality is very resistant to treatment. 

Ringworm is distinguished from eczema of the scalp in that in 
eczema there is more itching and the patches are not so circular and 
do not have the broken hairs seen in ringworm. There are not the 
crusts in ringworm seen in eczema. 

Treatment. — The application of pure tincture of iodin or cor- 
rosive sublimate (three grains to an ounce of water) to the spots with 
a camel's hair brush, once daily for three days, will usually cure 
ringworm on the skin. On the scalp the hairs should be pulled out 
of the patch of ringworm, and each day it should be washed with 
soap and water and a solution of boric acid (as much acid as the 
water can dissolve) , destroying the cloth used for washing. Sulphur 
ointment is then applied (sulphur one part, and lard seven parts). 

It is desirable to secure the services of a physician in this disease, 
in which various remedies may have to be tried to secure recovery, 
which is at best usually a matter of several months. 

FRECKLES, TAN AND OTHER DISCOLORATIONS OF THE SKIN 

Freckles appear as small, yellowish-brown spots on the face, arms, 
and hands, following exposure to the sun in summer, and generally 
fading away almost completely in winter. However, sometimes they 
do not disappear in winter, and do occur on parts of the body covered 
by clothing. Freckles are commonly seen in red-haired persons, rarely 
in brunettes, and never on the newborn. Their removal is accom- 
plished by the employment of agents which cause a flaking off of the 
superficial layer of discolored skin, but after a few weeks the discolor- 
ations are apt to return. 

Large, brown spots of discoloration appearing on the face, or 
liver spots (chloasma), are observed more often in women, and are 
due to disorder of the digestive organs, of the sexual organs or to 
pregnancy; they also occur in persons afflicted with exhausting 
diseases. 



SKIN DISEASES 155 

Tan, freckles, and discolorations of the skin generally are bene- 
fited by the same remedies. 

Treatment. — Prevention of tan and freckles is secured through 
non-exposure of the unprotected skin to the sun, though it is doubtful 
whether the end gained is worth the sacrifice, if carried so far as 
avoidance of the open air and sunlight whenever possible. The wear- 
ing of a veil and protecting the skin with an application of calamin 
lotion before exposing the face, will also prevent freckles and tan. 

Pure hydrogen dioxid applied several times daily to the skin is 
harmless and may remove freckles and discolorations. The dark 
patches, or liver spots, on the face of women are best treated by atten- 
tion to any existing disease of the womb or ovaries. 

The following lotion is efficacious : 

Zinc oxid 30 grains 

Powdered starch 30 " 

Kaolin 60 " 

Glycerin 2 drachms 

Eose water 2 ounces 

Mix. 

Directions. — Shake and paint on spots, and allow the preparation 
to dry; wash it off before each fresh application. 

It is best to use only cold water, rarely soap, on the healthy 
skin of the face. Warm water favors relaxation of the skin and 
formation of wrinkles, 

IVY POISON 

The poison ivy (Rhus toxicodendron), poison sumach (Rhus ven- 
enata), and poison oak (Rhus diversiloba of the Pacific Coast, U. S., 
A.), cause inflammation of the skin in certain persons who touch 
any one of these plants, or in some cases even if approaching 
within a short distance of them. The plants contain a poisonous 
oil, and the pollen blown from them by the wind may thus convey 
enough of this oil to poison susceptible individuals who are even a 
considerable distance away. Trouble begins within four or five hours, 
or in as many days after exposure to the plants. 

Symptoms. — The skin of the hands becomes red, swollen, painful, 



156 SKIN DISEASES— BITES AND STINGS OF INSECTS 

and itching. Soon little blisters form, and scratching breaks them 
open so that the parts are moist and then become covered with crusts. 
The poison is conveyed by the hands to the face and, in men, to the 
sexual organs, so that these parts soon partake of the same trouble. 
The face and head may become so swollen that the patient is almost 
unrecognizable. 

There is a common belief that ivy poison recurs at about the same 
time each year, but this is not so except in case of new exposures. 
Different eruptions on the same parts often follow ivy poisoning, 
however. 

Treatment. — A thorough washing with soap, especially green 
soap, will remove much of the poison and after effects. Saleratus or 
baking soda (a heaping tablespoonful to one pint of cold water), or 
lime water may be used. The best treatment consists in soaking sev- 
eral layers of soft cotton or linen cloth or gauze in one of these 
solutions, or better in calamin lotion, and keeping the application 
wet on the part day and night. On the arms and hands the application 
can be kept wet by covering it with oil silk or rubber cloth and band- 
age. On the face the wet application may be removed at night and 
cold cream or zinc ointment may be used. 

WARTS 

( Verruca) 

Warts are flattened or rounded outgrowths from the outer and 
middle layers of the skin, varying in size from a pin head to half 
an inch in diameter. There are several varieties. The common wart 
occurs more often on the hands of children or young people and may 
be of various colors — yellow, brown, black, or green. They may be 
numerous, single, or in groups. 

Seed Warts. — These have numerous, little, fleshy projections 
over their surface, which are enlarged normal structures (papillae) 
of the middle layer of the skin, together with the thickened, outer, 
horny layer. 

Threadlike Warts. — These are seen along the edge of the nails, 
on the face, neck, eyelids, and ears. They are formed by the great 



SKIN DISEASES 157 

prolongation and growth of the projections, or papillae of the middle 
layer of the skin just described. 

Flat Warts. — In young persons they occur on the face and backs 
of the hands. In old persons they are seen on the body and arms, 
and are dark. 

Moist Warts. — Moist warts occur where they are softened by 
secretions of the body, as about the sexual organs (in connection with 
diseases of the same), and about the anus (or opening of the bowel), 
in the armpit, under the breast in women, and between the toes. 
They are of a white, pink, or red color, and consist of numerous, 
little fleshy projections, usually covered with a foul-smelling secretion. 

Causes. — Warts appear to be slightly contagious, for persons have 
occasionally acquired warts by handling them on other individuals, 
and a crop of warts may develop from a single one. They may dis- 
appear quickly or remain indefinitely. 

Treatment. — The most rapid method of removing warts is by 
stretching the skin and scraping them off with a sharp spoon under 
cocain ; this is not applicable when there are large numbers of warts 
or unless done by a physician. A slower method is by painting the 
warts three times daily with a mixture of one drachm of salicylic acid 
in four drachms of collodion. Every few days the collodion should 
be pulled off and the softened surface removed by rubbing the warts 
with sandpaper or pumice stone — after soaking them in hot water. 

When warts are very numerous they may be removed by bathing 
them twice daily in a saturated alcoholic solution of salicylic acid 
and scraping off the soft parts, as described. The application of pure 
carbolic, acetic or lactic acid to single warts, by means of a toothpick 
twice daily, may be efficient. The small thread or taglike warts on 
the neck may be cut off by curved scissors, which have lain in alcohol 
Rve minutes, and the remaining raw spot touched with a pencil of 
silver nitrate. The moist warts should be kept absolutely clean by 
soap and water and then powdered alum may be dusted over the skin. 
The use of the electric needle or freezing, in the hands of specialists, 
have proven successful in removing warts. Warts may sometimes 
be removed by painting them frequently with the fresh juice of the 
milkweed. 



158 SKIN DISEASES— BITES AND STINGS OF INSECTS 

BALDNESS 

Baldness is commonly classed in three groups: 

1. The first group includes about three-quarters of all cases of 
baldness and is due to dandruff or, more precisely, the skin disease 
which causes dandruff. This is usually an inflammation (seborrhea) 
affecting chiefly the glands supplying oil to the hair, and after a 
time the trouble extends to the hair roots, so that the hair gets dry 
and fine, and later falls out. 

Dandruff is composed of yellowish, greasy plates, or crusts, or 
dry, thin scales. The disorder is supposed to be due to a parasite, and 
to be somewhat contagious, so that persons having dandruff should 
not use the brush or combs of others. Dandruff is usually present for 
many years (two to seven) before the hair begins to fall, but as 
the baldness increases the dandruff decreases. 

2. In another smaller group of cases the baldness is said to be 
premature, that is, it appears early, without any disease of the skin, 
and is apparently an inheritance. 

3. Finally, there is the form of baldness seen in children or 
adults in which bald spots suddenly make their appearance in the 
midst of a thick crop of hair. Sometimes neuralgic pains are felt in 
the head for days previously. The cause is unknown ; the disease may 
be parasitic and slightly contagious, or due to some nervous disturb- 
ance. It tends to recovery without treatment within several months 
to years, although a return of the trouble is common. Baldness is 
frequently due to syphilis, when it may be cured by antisyphilitic 
remedies. Complete baldness, so common in men, is rarely seen in 
women. 

Treatment. — To prevent premature baldness proper care of the 
hair must be pursued from birth. The baby's head should be washed 
daily and then anointed with vaselin until the hair begins to grow T , 
when a soft brush may be used and the vaselin dispensed with. The 
child's hair should not be cut short, and after the eighth or ninth 
year a girl's hair should be allowed to grow. Daily wetting of the 
hair, to make it part or lie smooth, is harmful. Shampooing may 
be done with any good toilet soap once in two or three weeks. The 



SKIN DISEASES 159 

most efficient preventive of baldness is long and careful brushing, 
several times daily, with a brush having long, fairly stiff bristles but 
not so stiff as to make the scalp sore. Tightly fitting hats are in- 
jurious. Daily massage of the scalp, so that the skin is picked up 
in folds, is of great value. Also exercise and improvement of the 
general health are most important. 

When premature baldness is beginning the following ointment 
should be rubbed well into the scalp daily. Thorough brushing, atten- 
tion to the general health and massage of the scalp are of chief 
value, however. 

Formula for Ointment 

Pilocarpine hydrochlorid 30 grains 

Vaselin 5 drachms 

Oil of lavender 25 drops 

Lanolin 2 ounces 

External use (Lassar). 

In the baldness beginning with dandruff it is wiser to treat the 
disease causing the dandruff (seborrhea) before the hair falls out. 
The head should be shampooed with soap and water (tar soap is 
useful) and when dry the scalp (not the hair) should be anointed with 
sulphur ointment (1 drachm of precipitated sulphur in 1 ounce of 
cold cream) every night ; once a week the head should be washed. 

After daily application of the sulphur ointment for a week the 
ointment may be applied but every other night the second week, and 
twice the third week, and once the fourth week, at which time the 
dandruff should be cured. 

If baldness is beginning the sulphur ointment must be applied 
daily for several months ; when there is absolute baldness it is prob- 
able that no remedy will make the hair grow again. While women 
suffer from this disease with dandruff they do not become absolutely 
bald as a result of it, as men do. 

THE ITCH 

(Scabies) 

Causes. — This disease is caused by the burrows of an insect or 
mite under the skin in special regions, as between the fingers, under 



160 SKIN DISEASES— BITES AND STIXGS OF IXSECTS 

surface of the wrists, about the navel, breasts, and privates of men. 

Symptoms. — At these places there will be seen scratch marks and 
often little blisters, pimples, and red patches. Itching is very great, 
especially at night, and when it begins there is no skin eruption 
visible. The presence of intense itching and scratch marks at the 
places noted, particularly if more than one member of a family is 
affected, is usually sufficient to make a diagnosis. 

Treatment. — After the patient takes a thorough soap and water 
bath and is dry he should rub all affected places with sulphur oint- 
ment night and morning for three days, while wearing the same 
underclothes, nightclothes and sheets. Then he may take another 
bath and use clean clothes, dusting sulphur over the body and between 
the sheets for a week, at bedtime. The soiled body clothing and bed 
clothing should be boiled. In children a mixture of Peruvian balsam 
and sweet oil. equal pans, may be used instead of sulphur ointment. 

CALLUS AND CRACKS OF THE SKIN 

Symptoms. — Callus consists of round or irregular, flattened, 
yellowish thickenings of the upper or horny layer of the skin. The 
skin becomes hypertrophied and resembles a thick, horny layer caused 
by intermittent pressure of tools, shoes, etc. The whole palm of the 
hand or soles of the feet may be the seat of a continuous callus. 

Callus is not harmful, except in leading to cracks of the skin near 
the bend of joints, and, rarely, in causing irritation, heat. pain, 
and even the formation of pus in the skin beneath. Callus usually 
disappears when the exciting cause or pressure is removed. 

Treatment. — The hands and feet should be soaked continuously in 
hot baths containing washing soda, and then should be covered with 
diachylon, or other ointment. This may be done each night : or col- 
lodion (one ounce containing sixty grains of salicylic acid) may be 
painted on the callus, night and morning for several days, and then, 
after soaking for some time in hot water, the surface should be 
scraped off with a dull knife and the process repeated as often as 
necessary to effect a core. 

Fissure or cracks of the skin caused by callus are treated by pro- 
longed soaking in hot water, paring away the edges so as to diminish 



SKIN DISEASES 161 

the depth of the crack, and then applying compound tincture of ben- 
zoin with a camel's hair brush to the crack twice daily, and cold 
cream to the skin at bedtime. Inflammation about callus must be 
cared for as recommended for inflamed corns. 

ECZEMA 

(Salt Rheum — Tetter) 

Ec'zema (not ec-ze'ma) is very common, constituting one-third 
of all skin diseases. 

Causes. — It is not contagious but is due to some external or 
internal irritant in persons whose skin is unusually sensitive. Cer- 
tain disorders favor its occurrence, as indigestion, constipation, 
anemia, Bright's disease, diabetes, uterine troubles, rheumatism, gout, 
and nervous diseases. Among external irritants causing eczema are 
included the action of the sun, wind, hot and cold weather, cold water, 
external heat, chemicals, injuries, chafing, parasites and varicose 
veins. 

Eczema is a form of catarrh of the skin, in that there is usually, 
but not always, moisture secreted at some period of the disease. The 
skin at times may be merely swollen and red, itchy and dry through- 
out the whole course of eczema. But moisture in an itching skin 
disease is almost always a sign of eczema. 

Symptoms. — There are seven prominent symptoms of eczema. 
These are redness, itching, swelling, moisture, crusting, scaling, and 
cracking. The disease occurs in spots which soon spread into patches. 
The occurrence of patches in a skin disease is another sign suggestive 
of eczema ; still another one usually present at some time in eczema is 
the appearance of minute blisters the size of a pin head. These in 
rupturing give rise to the moisture, which is sticky and gluey. 

The disease often attacks the face and scalp, the folds of the 
joints and the limbs. The disease may be shortlived or last for years ; 
frequent return of the trouble is to be looked for. 

Various Forms. — Five forms of the disease are usually described. 
These, however, frequently run into each other. Thus the disease 
may begin with a crop of red, itchy pimples, then blisters may form 
on the pimples; these may break and form a red moist patch, or 



16-2 SKIN DISEASES— BITES AND STINGS OF INSECTS 

matter may form in the blisters; and finally recovery occurs with 
crusting or scaling. 

The common forms are as follows: 

1. In this form there are swelling and redness of the skin with 
burning and itching (erythematous) ; the face, neck, hands, and but- 
tocks are favorite sites. Small spots may run together and form 
patches. The patch may not be moist unless from scratching. The 
duration of the disease may be short or become chronic. Recovery 
occurs with the disappearance of redness and swelling and the ap- 
pearance of branny scales. 

2. This is the pimply and most itchy form (papular). There is 
an eruption of dull red pimples of a pin-head size, which frequently 
form patches as large as a silver dollar. These occur on the back, 
arms, hands and legs. They may become capped with minute blisters 
which give rise to moist patches when they are broken by scratching. 

3. The most common form of all is that in which there are great 
numbers of little pin-point sized blisters on a raw, red surface (vesic- 
ular). This occurs more often on the face, hands, neck, and but- 
tocks. There is intense burning and itching, the secretion is thick 
and sticky, and forms crusts in drying. When the crusts are re- 
moved the surface beneath is raw. The blisters are present such a 
short time that they may not be seen. Finally, the redness disap- 
pears, the swelling subsides, and scaling heralds recovery. 

4. Matter or pus may form in the blisters and this variety (pus- 
tular) often attacks the face or scalp in children. Pus germs are 
commonly inoculated into the skin through scratching, and the secre- 
tion in drying produces thick, yellowish or greenish crusts. The 
burning and itching are not so marked as in the other forms of 
eczema. 

5. The form of eczema in which the skin is dry, red, covered 
with scales, like dandruff, may be chronic with thickened skin which 
cracks readily, or it may simply be the final stage of any variety of 
eczema preceding recovery. 

Eczema may be general and give rise to serious symptoms or be 
confined to a small patch. Being prone to recur when apparently 
cured it is impossible to forecast the future in any given case. When 



SKIN DISEASES 163 

the disease becomes chronic recovery is a slow matter. Eczema 
never threatens life, however, and practically all cases can be cured ; 
the only uncertainty is whether there will be a return of the trouble. 

Treatment. — The treatment of eczema is a puzzling matter for 
physicians, and only specialists in skin diseases can handle cases to 
best advantage as the remedies have often to be varied from time 
to time to suit the changing conditions of the skin. The diagnosis 
in some of its forms is also a difficult matter. Only some general 
suggestions can therefore be made for the home management of 
eczema. 

In general the diet should contain but little meat in cases of 
eczema. In acute cases the diet for the first few days should be con- 
fined to milk (2 quarts), cereals and bread or toast. Patients should 
drink at least nine glasses of water daily, one before and at each 
meal, and one between meals and at bedtime. Alcohol in all forms, 
and tea and coffee, should be excluded from the diet. In ordinary 
cases of subacute and chronic eczema a simple diet chiefly of cereals, 
vegetables and fruit, with meat once daily, and plenty of water are 
advised. 

The bowels should be kept regular by diet and exercise, if pos- 
sible, but if this is not successful some of the drugs recommended in 
this volume may be used. ~Ro special remedy taken internally is of 
much use in eczema unless the system particularly demands it — as 
iron in anemia, and cod-liver oil in the thin and undernourished. 

Local Treatment. — Xeitker soap nor water must be used in 
eczema. The eruption should be cleaned by wiping with oil instead. 
Scratching is injurious and must be prevented. In children the 
hands may be enclosed in Canton flannel bags, or the sleeves pinned 
to the clothes in infants; or, if on the face, the child may wear a 
muslin mask with holes cut for the eyes, mouth and nose. If there 
are crusts on the skin they must be removed by soaking over night in 
sweet oil before applying other remedies. 

In the treatment of eczema by drugs we should use soothing 
remedies in the stage with great redness, swelling and burning. In 
the form with less redness and swelling, but with moisture, pimples, 
crusts, and itching, agents drying up the skin are advisable — as the 



164 SKIN DISEASES— BITES AND STINGS OF INSECTS 

zinc preparations. Finally, in chronic eczema, or when the other 
remedies do not cure, some of the tar compounds are most valuable 
in stimulating the skin, and so favoring recovery as well as relieving 
the itching. 

In the beginning of eczema, when there is most swelling, red- 
ness, burning and itching, sopping the skin frequently with a solution, 
consisting of two heaping teaspoonfuls of boric acid or baking soda 
to one pint of water, and then powdering it with cornstarch flour and 
covering with old cotton or linen and bandage, is effective. Calamin 
lotion, as previously described, is also an excellent preparation when 
sopped on with a piece of old soft muslin several times a day. If 
the itching is not relieved by this, ten to twenty drops of pure car- 
bolic acid may be added to four ounces of calamin lotion. 

After the disease has lasted some days and the redness and 
swelling have somewhat departed, or in the form where there is 
moisture, crusts, blisters, or pimples, one of the drying preparations 
is desirable. Zinc ointment is the simplest. Lassar's paste is some- 
times more effective, as follows : 

Zinc oxid 2 drachms 

Starch 2 

Vaselin 4 " 

Mix and apply externally. 

This, or zinc ointment, should be spread on soft old cotton or 
linen, as one would spread butter on bread very thickly. Then it is 
placed so as to cover the eruption and held in place by a bandage. 
The dressing should be renewed twice daily. Calamin lotion is useful 
in this stage also. When these do not cure one may add fifteen 
drops of oil of cade (a tarlike substance) to each ounce of zinc oint- 
ment. In the more chronic, scaly eczema, one drachm of oil of cade, 
or two drachms of liquid tar, may be added to each ounce of zinc 
ointment ; or liquid tar dissolved in twice as much alcohol is painted 
on the eruption and, when the alcohol has evaporated, the skin is 
covered with pure zinc ointment. Comparatively small patches of 
chronic, scaling eczema are treated by rubbing pure tar into them or 
applying sulphur ointment. 



SKIN DISEASES 165 

Specialists sometimes find the use of the x-ray and other means 
not open to the laity beneficial in chronic eczema. 

ERYSIPELAS 

Causes. — Erysipelas is a disease caused by germs (streptococci) 
which gain entrance through some wound or abrasion in the skin or 
mucous membranes. Even where no wound is evident it may be 
taken for granted that there has been some slight abrasion of the 
surface, although invisible. Erysipelas cannot be communicated 
any distance through the air, but it is contagious in that the germs 
which cause it may be carried from the sick to the well by nurses, 
furniture, bedding, dressings, clothing, and other objects. Thus, 
patients with wounds, women in childbirth, and the newborn, may 
become affected, but modern methods of surgical cleanliness have 
largely eliminated these forms of erysipelas, especially in hospitals, 
where the disease used to be common. 

Erysipelas attacks people of all ages, some persons being very 
susceptible and suffering frequent recurrences. The form which 
arises without any visible wound is seen usually on the face, and 
occurs most frequently in the spring. The period of development, 
from the time the germs enter the body until the appearance of the 
disease, lasts from three to seven days. 

Symptoms. — Erysipelas usually begins with a severe chill (or 
convulsion in a baby) and fever. Vomiting, headache, and general 
lassitude are often present. A patch of red appears on the cheeks, 
bridge of the nose, or about the eye or nostril, and spreads over 
the face. The margins of the eruption are sharply defined. 

Within twenty-four hours the disease is fully developed; the 
skin is tense, smooth, and shiny, scarlet and swollen, and feels hot, 
and is often covered with small blisters. The pain is more or less 
intense, burning or itching occurs, and there is a sensation of great 
tightness or tension. On the face the swelling closes the eye and 
may interfere with breathing through the nose. The lips, ears, and 
scalp are swollen, and the person may become unrecognizable in a 
couple of days. Erysipelas tends to spread like a drop of oil, and 
the borders of the inflammatory patch are well marked. It rarely 



166 SKIN DISEASES— BITES AND STINGS OF INSECTS 

spreads from the face to the chest and body, and but occasionally 
attacks the throat. During the height of the inflammation the tem- 
perature reaches 104° F., or over. 

After four or five days, in most cases, erysipelas begins to sub- 
side, together with the pain and temperature, and recovery occurs 
with some scaling of the skin. The death rate is said to average 
about ten per cent, in hospitals, four per cent, in private practice. 
Headache, delirium, and stupor, are common when erysipelas attacks 
the scalp. The appearance of the disease in other locations is similar 
to that described. Relapses are not uncommon, but are not so 
severe as the original attack. Spreading may extend over a large 
area, and the deeper parts may become affected, with the formation 
of deep abscesses and great destruction of tissue. 

Certain internal organs — heart, lungs, spleen, and kidneys — are 
occasionally involved with serious consequences. The old, the dis- 
eased, and the alcoholic are more apt to succumb, also the newborn. 
It is a curious fact that cure of malignant growths (sarcoma), 
chronic skin diseases, and old ulcers sometimes follows attacks of 
erysipelas. 

Treatment. — The duration of erysipelas is usually from a few 
days to about two weeks, according to its extent. It tends to run 
a definite course and to recovery in most cases without treatment. 

The patient must be isolated in a room with good ventilation and 
sunlight. Dressings and objects coming in contact with him must be 
burned or boiled. The. diet should be liquid, such as milk, beef 
tea, soups, and gruels. 

The use of cloths wet constantly with cold water, or with a cold 
solution of one-half teaspoonful of pure carbolic acid to one pint of 
hot water, or with a (poisonous) solution of sugar of lead, four 
grains to the pint, should be kept over small inflamed areas. Fever 
is reduced by sponging the whole naked body with cold water at 
frequent intervals. A tablespoonful of whisky or brandy in water 
may be given every two hours to adults if the pulse is weak. Paint- 
ing the skin with pure tincture of iodin all about the inflamed area 
may prevent its spreading. 

Recently a serum (antistreptococcic) obtained from a horse 



BTTES AND STINGS OF INSECTS 167 

immunized against the erysipelas germs (streptococci), and a vaccine, 
made of the killed germs of the disease, have been injected under 
the skin with some success. The patient must be quarantined until 
all scaling ceases — usually for two weeks. 



BITES AND STINGS OF INSECTS 

MOSQUITOES 

The female mosquito is the offender. During or after sucking 
blood she injects a poison into the body which causes itching, swell- 
ing, and, in some susceptible persons, considerable inflammation of 
the skin. The bites of the mosquitoes living on the shores of the 
Arctic ocean and in the tropics are the most virulent. The most 
important relation of mosquitoes to man was only recently dis- 
covered ; they are the sole cause of malaria and yellow fever in the 
human being. 

Treatment for Prevention of Mosquito and Other Insect Bites. 
— To prevent mosquitoes, fleas, lice, horseflies, etc., from biting, it is 
necessary merely to dip the clean hands into a pail of water in 
which, while hot, one ounce of pure carbolic acid was dissolved, and 
while they are thus wet rub the solution over all the exposed skin 
and allow it to dry naturally. A solution containing Epsom salts, 
one ounce to the pint of cold water, may be used in the same way. A 
mixture of kerosene (petroleum) and water used in the same manner 
will also afford protection. A more elegant protection against insect 
bites is attained by rubbing the skin with one of the essential oils, as 
oil of lavender, Eucalyptus or pennyroyal, which may be carried in a 
small bottle in the pocket. 

Treatment for Relief of Stings. — All poisons introduced into the 
body by insects are of an acid nature (chiefly formic acid) and to 
this is due the pain and irritation which it is our object to over- 
come. The best remedy, naturally, is an alkali of some sort. Water 
of ammonia, diluted, or a strong solution of saleratus or baking soda 
in water, are the two most successful remedies to apply, either 
through bathing, or on cloths saturated in one of the solutions. 



168 SKIN DISEASES— BITES AND STINGS OF INSECTS 

Clean clay, mixed with water to make a mud poultice, is a useful 
application in emergencies. 

BEES> WASPS, AND HORNETS 

The pain and swelling are produced by the poison of the insect 
which leaves the poison bag at the base of the barb at the instant 
the person is stung. The bee stings but once, as the sting, being 
barbed, is broken off, and is retained in the flesh of the victim. The 
sting of the wasp and hornet is merely pointed, and is not lost during 
the stinging process so that they can repeat the act. Bee keepers, 
after being stung a number of times, usually become immune, i.e., 
they are no longer poisoned by bites of these insects. 

Treatment. — It is well to extract the sting of bees before all of 
the poison has come away. A fine pair of forceps is useful for this 
purpose; or, by pressing the hollow tube of a small key directly 
down over the puncture made by the sting, it may be squeezed out. 

Spirit of camphor or diluted ammonia water, as recommended for 
mosquitoes, and moist clay or earth are the best remedies to relieve 
the pain. 

WOOD TICKS 

Ticks inhabit the woods and bushes throughout the temperate 
zone, and at certain periods during the summer season attack passing 
men and animals. 

The common tick is nearly circular in shape, very flat, with a 
dark, brown, horny body about one-sixteenth to one-eighth inch in 
diameter. Each of its eight legs possesses two claws, and the proboscis 
incloses feelers which are similarly armed. The beetle plunges its 
barbed proboscis into the flesh of man or animals, and holds on very 
firmly with its other members till it is gorged with blood, growing 
as large as a good-sized bean, when it drops off. The bite is painless, 
and it is not until the insect is engorged with blood that it is per- 
ceptible; if, however, attempts are made to remove the tick before 
it is ready to go, the proboscis may be torn off and left in the skin, 
when painful local suppuration will follow. 

Ticks are the sole means of transmitting Rocky Mountain fever 
to man and Texas fever to cattle. 






BITES AND STINGS OF INSECTS 169 

Treatment. — As the presence of ticks is far from agreeable, the 
insect may be removed by painting it with turpentine, which either 
kills it or causes the claws to be relaxed, or moist tobacco may be 
laid over the tick ; in either case the tick loosens its hold and drops 
to the ground. A tropical variety, carapato, buries the whole head 
in the flesh of its host before it is perceived, and if turpentine does 
not loosen its hold, the head must be dug out with a clean needle or 
knife blade. 

LICE 

(Pediculi) 

Head lice are most common. They are gray with black margins, 
about one-twenty-fifth to one-twelfth inch long, and wingless. The 
color changes with the host, as the lice are black on the Negro, and 
white in the case of the Eskimo.' The female lays fifty to sixty eggs 
(nits), seen as minute, white specks glued to the side of a hair — 
usually not more than one or two on a single hair. The eggs hatch 
in six days. 

Symptoms. — The irritation produced by the presence of the para- 
sites on the head leads to general itching, more particularly on the 
lower part of the back of the head. The constant scratching starts an 
inflammation of the skin with formation of pimples, weeping spots, 
and crusts, from the dried discharge, possessing a bad odor. The 
denuded spots becoming infected, the neighboring glands enlarge and 
are felt as tender lumps beneath the skin at the back of the neck, 
under the jaw, or at either side of the neck. Whenever there is 
persistent itching and irritation of the scalp, particularly at the 
back of the head, lice, or nits should be sought for; sometimes it is 
more easy to find them on a fine-toothed comb passed through the 
hair. Lice are very common in dirty households, and are occasionally 
seen on the most fastidious persons, who accidentally acquire them in 
public places or conveyances, or from servants. 

Treatment. — The hair should be cut short when permissible. Any 
crusts on the head should be softened by the application of sweet 
oil, and then removed by washing with soap and warm water. 
Petroleum or kerosene, mixed with an equal amount of sweet oil, 
is a good remedy. It must be rubbed on the head two successive 



170 SKIN DISEASES— BITES AND STINGS OF INSECTS 

nights, the head being covered by a cap, and washed off each 
morning with hot water and soap. The patient must be cautioned 
not to approach an open flame after kerosene has been put on his 
head. 

The eggs, or nits, are next to be attacked with vinegar, which is 
sponged on the hair and the fine-toothed comb plied daily for a week. 
The remaining irritation of the scalp can be cured by washing the 
head daily and applying sweet oil. 

A more simple plan consists of the drenching hair and scalp 
twice with cold infusion of (poisonous) larkspur seed, made by 
steeping an ounce of the seed in six ounces of hot water for an hour. 

This treatment will destroy both insects and eggs. After twenty- 
four hours the hair and scalp must be shampooed thoroughly with 
soap and warm water. In mild cases washing with equal parts of 
alcohol and water twice daily for several days will kill the lice. 

Clothes Lice 

These insects are a trifle larger than the head lice, being one- 
twelfth to one-eighth inch long, of a dirty, yellowish-gray color, and 
infesting the most filthy people. The lice are generally only seen 
on the clothes, where they live, coming out on the body to feed. 

Symptoms. — The visible signs on the body are varying degrees 
of irritation from redness to ulceration, due to scratching. 

Treatment. — The treatment is simply cleanliness of the body 
and clothes. A piece of sulphur or camphor, the size of a walnut, 
worn next to the skin in a piece of cheesecloth will protect the person 
from lice bites. 

Crab Lice 

The crab louse, or crab, inhabits the skin covered by hair about 
and above the sexual organs most frequently, and from thence spreads 
to the hairy region on the abdomen, chest, armpit, beard, and eye 
lashes. 

Symptoms. — Itching and scratching first call attention to the 
presence of the parasites, which are even more troublesome than the 
other species. 



BITES AND STINGS OF INSECTS 171 

Treatment. — Application of corrosive sublimate (poisonous) in 
solution (two grains to one ounce of water) to the part is sufficient 
to kill the lice, but this treatment must be repeated several times at 
intervals of a week, in order to kill the parasites subsequently 
hatched. Kepeated washing of the hair with vinegar will remove the 
nits (eggs). 

FLEAS 

Fleas, unlike lice, do not breed on the body, but as soon as they 
are satiated leave their host. Their eggs are laid in cracks in floors, 
on dirty clothes and similar spots, and it is only the mature flea 
which preys upon man. The human flea may infest the dog and 
return to man, but the dog flea is a distinct species, and never 
remains permanently on the human host. For these reasons it is not 
difficult to get rid of fleas after they have attacked the body, unless 
continually surrounded by them. 

Symptoms. — Flea bites are recognized by the itching caused by 
the poison introduced by the insect, and by points of dried blood 
surrounded for a little while by a red zone. In the case of children 
and people with delicate skins, red or white lumps appear resembling 
nettlerash. Generally the skin is simply covered with minute, red 
points, perhaps raised a little by swelling above the surface, and 
when very numerous may remotely resemble the rash of measles. 

Treatment for Prevention of Flea Bites. — Bags of Persian in- 
sect powder worn next to the skin will prevent the bites of fleas. 

Bubonic plague is spread only by fleas from rats (having the 
disease) biting man. 

BED BUGS 

The bed bug is a brown oval-shaped insect of repulsive odor. It 
is capable of conveying any infectious disease from the blood of one 
person to another through its bites, so that the domestic horror it 
inspires is not imaginary. It lives in crevices in wall paper, bed- 
steads, furniture, woodwork, etc., and is very hard to get rid of. 

Fumigation, Etc. — Oil of turpentine should be applied to all the 
inner surfaces of the bed, to the spring and the bedding and bed, and 
the room should be fumigated with sulphur once every two weeks 
until no further signs of the bugs appear. 



172 SKIN DISEASES— BITES AND STINGS OF INSECTS 

Sulphur c-andles may be bought for the purpose, but three pounds 
are required for an ordinary room sealed tight. Persian insect 
powder placed in the bed will prevent bugs from biting a person. 

Treatment. — Small lumps on the skin with purple spots in the 
center, are the result of bed bug bites. The application of carbolized 
vaselin will relieve the irritation. 

JIGGERS OE SAND FLEAS 

I Ghique, Chigo, and Xigua) 

The jigger is common in Cuba. Porto Pdco and Brazil. About 
one-half the size of the ordinary flea, it is of a brownish-red color 
with a white spot on the back. The female lives in the sand and 
attacks man on whom she lives, boring into the skin about the toe 
nail usually, and laving her egg:s under the skin, which gives rise to 
itching at first and then violent pain. 

The insect sucks blood and grows as it gorges itself, producing a 
white swelling of the skin, in the center of which is seen a black 
spot, the nut part of the flea. The flea after expelling its eggs 
drops off and dies. People with habitually sweaty feet are exempt 
from attacks of the pest. 

Unless the flea is unattached, one must either wait until the 
insect comes away oi its own free will, or remove it with a red-hot 
needle in order to destroy the eggs. The negroes peel the skin from 
the swelling with a needle and squeeze out the eggs. Ordinarily 
the bites do no permanent injury, but occasionally, if numerous, or 
if the insect is pressed into the skin in the effort- to remove it. or if 
sores resulting from bites are neglected, then violent inflammation, 
great pain, and even death of the part may result. 

Sound shoes and a night and morning inspection of the feet will 
protect against the inroads of the sand fleas. 

FEIES 

The common housefly does not bite, but is constantly inimical to 
human health by conveying disease germs from typhoid fever, 
cholera, and other disorders from bowel discharges of patients suf- 



BITES AND STINGS OF INSECTS 173 

fering from these diseases to articles of food on which the insects 
light. Flies have been a fruitful source of sickness in military 
camps (the recent Spanish-American and Anglo-African campaigns). 
Prevention and Relief. — The bites of the sandfly, gadfly, and 
horsefly may be both relieved and prevented by the same means 
recommended in the case of mosquitoes for these purposes. 

SCORPIONS— CENTIPEDES 

These both inhabit the tropic and semitropical regions, and lurk 
in dark corners and out-of-the-way places, crawling into the boots 
and clothing during the night. Scorpions sting with their tails, 
which are brought over the head and back for the purpose, while 
holding on to the victim with their lobsterlike claws. The poisonous 
centipede has a flattened brownish-yellow body, with a single pair 
of short legs for each body segment, and long, many- jointed antennae. 

The wounds made by either of these pests are rarely dangerous, 
except in young children or those in feeble health. The stings are 
usually relieved by bathing with a two per cent, solution of carbolic 
acid, with rum, or with lemon juice. 

SPIDERS 

Many of the tropical spiders bite the human being. Trapdoor 
spiders are among the most common of these pests. Their bodies 
grow to great size, two to two and one-half inches long, and are 
covered with hair, giving them a horrible appearance. They live in 
holes bored in the ground, and provided with a trapdoor contrivance 
which is closed when the insect is at home. 

The trapdoor spider resembles the tarantula, by which name it 
is usually known in Cuba and Jamaica, but is somewhat smaller and 
more common. Neither the stings of the trapdoor spider nor true 
tarantula are usually dangerous, although the wounds caused by 
the bites may heal slowly. 

Treatment. — Application of diluted water of ammonia and of 
the other remedies recommended for mosquito bites are useful here, 
and if the patient is generally depressed by the poison, strong coffee 
forms a good antidote. 



CHAPTEE X 
POISONS AND ANTIDOTES— FOOD POISONING 

List of poisons and antidotes. Food poisoning, including meat, fish, cheese, 
ice cream, potato, and canned food poisoning. Tapeworm, round worms, 
pin worms. Trichiniasis. Hookworm disease. 

POISONS AND ANTIDOTES 

General Rules. — Be sure the person is actually poisoned and 
not merely frightened. Send for a doctor. Find the name of the 
poison, but waste no time if this is not easy. Do not empty the 
stomach if the poison is a strong acid or alkali (see Alkalis and Acids 
under list of Antidotes below). Otherwise empty the stomach by 
giving one tablespoonful of mustard stirred into a whole glass of tepid 
water. If this does not cause vomiting at once give two table- 
spoonfuls of common salt in a whole glass of tepid water. 

Then make the patient tickle the back of his throat with his finger, 
or tickle it with a feather. After vomiting has occurred give the 
patient two or three glasses of lukewarm water in rapid succession 
?*\d then tickle his throat to make him vomit it up again. By repeat- 
ing this several times it is possible to wash out the stomach, almost 
as well as the doctor with his stomach tube. Zinc sulphate one-half 
drachm is a most powerful emetic, but mustard and salt are generally 
efficient. Next give the patient milk in which have been stirred the 
whites of four raw eggs and a tablespoonful of whisky or brandy. 

As an antidote for any poison, when the poison is unknown, 
give one tablespoonful of powdered charcoal with one teaspoonful of 
magnesia, and one-half teaspoonful of tannic acid, mixed together in 
a glass of water. 

174 



POISONS AND ANTIDOTES 175 

Stimulation. — Most poisons depress the action of the heart and 
the breathing. After emptying the stomach and giving the milk, 
eggs, brandy (and charcoal, etc., if it is obtainable at once), get the 
patient flat on his back with no pillow nnder his head, cover him 
well and place hot water bags or bottles about his feet and legs. Do 
not burn him. Apply a mustard plaster or homemade paste (one 
part of mustard with two parts of flour mixed together in a paste 
and spread between two pieces of old cotton cloth or two handker- 
chiefs) over his heart. Give a tablespoonful of brandy or whisky 
in a little hot water every fifteen minutes, if weakness persists; 
strong black coffee is also a stimulant. If the stomach will not 
retain anything inject one pint of warm, strong, black coffee con- 
taining three tablespoonfuls of brandy or whisky, into the bowel, 
with a fountain syringe. Severe pain caused by irritant poisons 
may be relieved by fifteen to twenty drops of laudanum * in a little 
water, or one-quarter of a grain of morphin injected under the skin. 
These doses are for adults only. 

Definition of Antidote. — An antidote is a substance counteracting 
the effects of a poison by chemically altering it in the stomach or 
by antagonizing its effect on the body when the poison is absorbed. 
As antidotes are only partially successful it is always safer to empty 
the stomach first, unless it happens that the chemical antidote is at 
hand, when it may be given first and again after emptying the stomach 
to neutralize any poison not removed. 

Washing the stomach with a tube is the most effective method 
and that which the doctor uses. Following is a list of poisons and 
antidotes. When the name of the poison is known look for special 
treatment in this list. 

LIST OF POISONS AND ANTIDOTES 

Acetanilid, Antipyrin, Phenaoetin, Headache Powders Empty 

the stomach. Keep the patient flat on his back with his head low. 
Cover warmly and place hot water bottles at his feet. Inject one- 
half pint of strong black coffee with two tablespoonfuls of brandy 

1 Laudanum (opium) and morphin are powerful drugs, sold only on a doc- 
tor's prescription. 



176 POISONS AND ANTIDOTES— FOOD POISONING 

or whisky into the bowel, if there is vomiting. If the breathing fails 
perform artificial breathing. 

Acids 

Acetic, Muriatic, Nitric, Oxalic, Phosphoric, Sulphuric, and 
Tartaric Acids. — Do not empty the stomach. Give two teaspoonfuls 
of baking soda, or chalk, magnesia, or whitewash in a glass of water ; 
or powdered crayons, or plaster from the walls, or a glass of soap 
suds (laundry soap is best). After giving one of these, follow with a 
glass of milk, the white of four raw eggs and a cupful of sweet oil. 
Give stimulants (see Stimulation). 

Carbolic Acid. — Very common source of poisoning. Smallest 
fatal dose is one teaspoonful but more often one tablespoonful is fatal. 
Recovery has occurred from four ounces. 

Empty the stomach. Emetics commonly fail to act and so, if 
there is not a doctor at hand to wash out the stomach with ten per cent, 
alcohol,- give a tablespoonful of Epsom or Glauber's salts in a glass of 
water and milk and four raw eggs by the mouth. Brandy or whisky 
is advised as an antidote but merely makes the carbolic acid more 
soluble and is dangerous unless it can be washed out by a stomach 
tube. 

Give four tablespoonfuls of brandy and a pint of warm, strong, 
black coffee by the bowel, as advised in section above, on Stimulation. 
A doctor should also give subcutaneously camphorated oil, strychnin, 
and atropin. Artificial respiration is sometimes necessary. 

Aconite.— Empty the stomach. Patient absolutely quiet on the 
back. External heat (see Stimulation, page 175). 

Alkalis 
Ammonia, Quicklime, Caustic Potash, Lime, Soda, Lye, and 
Washing Soda. — Do not empty the stomach. Give one-half a glass 
of vinegar with an equal amount of water, or the juice of four lemons 
in a glass of water; or dilute solutions of muriatic, acetic, or citric 
acids. Follow with whites of four raw eggs, milk, and a cupful of 
sweet oil. Keep the patient warm in bed with head low, and stimu- 
late with brandy and black coffee. 



POISONS AND ANTIDOTES 177 

Other Poisons 

Antimony, Including Tartar Emetic and Other Salts. — Give two 
or three cups of strong tea, or better a teaspoonfnl of tannic acid in 
a glass of water. 

Vomiting is usually profuse from the poison. Give plenty of 
water to wash out the stomach. Keep the patient warm in bed and 
treat as advised in section above, on Stimulation. 

Antipyrin. — See Acetanilid. 

Arsenic. Including Paris Green, Scheele's and Schweinfurt's 
Green, White Arsenic, ' ' Rough-on-Rats, " and Fowler's Solution. 
— Empty the stomach very thoroughly ; then give four raw eggs and 
a glass of milk and magnesia as antidotes. The best antidote is the 
so-ca]led Arsenic Antidote kept by druggists. 

Belladonna, Including Atropin. — Empty the stomach. Give in- 
jection into the bowel of one pint of warm, strong, black coffee. 
Follow this by artificial respiration. The doctor should give caffein, 
strychnin and pilocarpin, subcutaneously. 

Camphor, Including the Spirits and Liniment. — Large doses of 
camphor may cause dizziness and convulsions but are rarely fatal. 
Empty the stomach. Apply heat, and stimulate as described in sec- 
tion above on Stimulation. If camphor has been taken in the solid 
state by children do not give alcoholic stimulants. 

Cannabis Indica, Indian Hemp. — While this drug may cause in- 
toxication and delirium it is not a fatal poison. Empty the stomach 
and arouse the patient. 

Cantharides — Spanish Flies. — Empty the stomach and give the 
whites of four raw eggs and milk, flaxseed tea and barley water. 
Avoid oils. Place hot poultices over the abdomen. Give the patient 
one teaspoonful of baking soda in one-half glass of water. Opium 
for pain as advised under Stimulation above. 

Chloral. — Empty the stomach. Give one pint of warm, strong 
coffee by the rectum, with brandy or whisky, and treat as recom- 
mended under paragraph on Stimulation. Try to keep the patient 
from sleeping; this may be accomplished by slapping him on the 
face and chest with a towel. It may be necessary to perform arti- 



178 POISONS AND ANTIDOTES— FOOD POISONING 

ficial respiration. A doctor should give strychnin and caffein sub- 
cutaneously. 

Chloroform (Swallowed). — Empty the stomach. Give one tea- 
spoonful of baking soda (bicarbonate of sodium) in a glass of water. 
Keep the patient from sleeping by slapping and pinching him. Give 
sweet oil to relieve the pain. Eollow the directions in section on 
Stimulation. 

Cocain. — Empty the stomach. Give brandy and whisky by the 
mouth or rectum. Let the patient inhale ether till he becomes quiet. 
Use stimulation as advised under the section on Stimulation. It 
may be necessary to do artificial respiration. A doctor should inject 
morphin, which, with ether, are the best antidotes. 

Colchicum. — Empty the stomach and give two cups of strong tea 
or one-half teaspoonful of tannic acid in a glass of water. It will 
be necessary to stimulate as described in the section on Stimulation, 
and also use opium or morphin to relieve the pain. A doctor should 
inject atropin, caffein and camphorated oil under the skin. 

Conium. — Empty the stomach. Then give two cups of very 
strong tea or one-half teaspoonful of tannic acid in a glass of water. 
Stimulate as described at the beginning of this chapter. Artificial 
respiration may be necessary. A doctor should give subcutaneously 
strychnin, camphorated oil, digitalone and atropin. 

Copper Salts, Including Blue Vitriol and Verdigris. — Fruit 
cooked in copper kettles may cause poisoning by copper. It is not 
necessary to empty the stomach, as vomiting occurs. Give the whites 
of four raw eggs and milk. Stimulate as described at the beginning 
of this chapter. Potassium ferrocyanid is the antidote. Opium is 
generally necessary for pain. Sweet oil will relieve the irritation in 
the stomach. 

Corrosive Sublimate. — Antiseptic Tablets and Solutions for 
Killing Bugs. — Empty the stomach. Give whites of four raw eggs 
and milk, also flour and water. Stimulate as described at the be- 
ginning of this chapter. A doctor should give morphin, digitalone, 
and atropin, subcutaneously. 

Creosote — Creolin. — See Carbolic Acid. 

Croton Oil. — This is one of the most powerful irritants known. 



POISONS AND ANTIDOTES 179 

Empty the stomach. Give the whites of four raw eggs and one pint 
of milk. Stimulate and give opium for pain. 

Digitalis. — Empty the stomach. Give two cups of strong tea or 
one teaspoonful of tannic acid. Stimulate as described at the begin- 
ning of this chapter. Give fifteen drops of the tincture of aconite 
to an adult. 

Formalin. — Used as a disinfectant. Give ammonia diluted; or 
repeat frequently, two tablespoonful doses of solution of ammonium 
acetate. Vomiting is severe, so that there will be no need to empty 
the stomach. Stimulate as advised at the beginning of this chapter. 

Gelsemium. — Empty the stomach, if noticed early. Stimulate as 
advised at the beginning of this chapter. Artificial respiration, pp. 
37, 42. A doctor should inject 1/50 grain of atropin subcutaneously. 

Holly Berries. — These are sometimes eaten by children. Empty 
the stomach, and stimulate as advised at the beginning of this chapter. 

Hydrocyanic Acid. — Empty stomach. Artificial respiration. Ex- 
ternal heat. 

Hyoscyamus. — See Belladonna. 

Iodin. — Tincture of iodin is often taken accidentally. Give a 
mixture of powdered starch and water at once. Eollow by emptying 
the stomach and then by giving the whites of four raw eggs and a 
glass of milk. Stimulate and give opium for pain. 

Iodoform. — Absorption from wounds or taken internally. Give 
teaspoonful doses of baking powder (sodium bicarbonate) in water. 
Stimulate with alcohol and heat as advised at the beginning of this 
chapter. 

Lead. — Poisoning from white or red lead, paint, sugar of lead, 
or its solution. Empty the stomach. Give one tablespoonful of 
Epsom salts in a glass of water. Follow with milk and the whites of 
four raw eggs and apply heat and stimulate as advised at the begin- 
ning of this chapter. 

Lime and Lye. — See Alkalis. 

Lobelia. — Empty the stomach. Give two strong cups of tea, or 
better one teaspoonful of tannic acid in a glass of water. Stimulate 
and give opium for pain. A doctor should inject caffein and cam- 
phorated oil under the skin. 



180 POISONS AND ANTIDOTES— FOOD POISONING 

Lysol. — See Carbolic Acid. 

Nitrate of Silver. — Empty tlie stomach, and give plenty of com- 
mon salt and water. Follow with the whites of four raw eggs, milk 
and sweet oil. Stimulate and give opium for pain. 

Opium and Morphin. — If taken by the mouth empty the stomach. 
The antidote is ten grains of potassium permanganate in a pint of 
water. This should be given as soon as possible and repeated in 
half an hour. Sometimes the stomach cannot be emptied with emetics, 
but antidote should be given whether this is possible or not. Do not 
allow the patient to sleep, pinch him, slap him with a wet towel, pour 
cold water on his head, and keep him moving about. Hold smelling 
salts at his nose. Give strong coffee to drink repeatedly. 

A doctor should inject atropin (one-twentieth of a grain to every 
grain of morphin taken), strychnin and caffein subcutaneously, and 
may use a faradic battery on the skin. Artificial respiration may 
be required. 

Nux vomica. — See Strychnin. 

Phenacetin. — See Acetanilid. 

Phosphorus, Including Sucking Matches, Rat Poison or Phos- 
phorus Paste. — There may be an odor of phosphorus in the breath. 
Empty the stomach. Give five grains of potassium permanganate 
in a glass of water or hydrogen peroxid, one ounce in a glass of water. 
The best emetic is copper sulphate, five grains every five minutes 
until vomiting ensues. Follow with one tablespoonful of Epsom 
salts. Give one-half a teaspoonful of baking soda three times daily 
for some days. Avoid all oils and fats. 

Potash. — See Alkalis. 

Strychnin — Nux vomica. — Empty the stomach at once. Give 
two cups of strong tea, or better one-half teaspoonful of tannic acid 
in a glass of water, and powdered wood charcoal freely mixed with 
water. 

If convulsions are present give inhalation of chloroform and two 
drachms of sodium bromid, and one-half drachm of chloral should be 
injected in a pint of water into the bowel. Artificial respiration 
may have to be done. 

Tobacco. — Empty the stomach, give one-half teaspoonful of tan- 



FOOD POISONING 181 

nic acid in water or two cups of very strong tea. Repeat these. 
Stimulate as described at the beginning of this chapter. Artificial 
respiration may have to be done. A doctor may have to inject cam- 
phorated oil and strychnin subcutaneously. 

Oil of Turpentine. — Empty the stomach. Give the whites of 
four raw eggs and a pint of milk; also one tablespoonful of Epsom 
salts in a glass of water. Stimulate and give opium for pain. 

Veronal. — This is often taken with suicidal intent. Uncon- 
sciousness and rash are seen on the body. 

Empty the stomach. Stimulate with coffee by rectum. The 
doctor should give caffein and strychnin, subcutaneously. 

Washing Soda. — See Alkalis. 

Wood Alcohol. — Empty the stomach. Stimulate with coffee by 
the rectum. Give also inhalation from bottle of smelling salts. 

Zinc Salts, Including White Vitriol and Butter of Zinc and 
Some Soldering Fluids. — Empty the stomach if vomiting has not 
been profuse. Give one-half teaspoonful of tannic acid in water, or 
two cups of strong tea, and the whites of four eggs. Stimulate as 
described at the beginning of this chapter. 



FOOD POISONING 

This is commonly but wrongly, in most cases, called ptomain 
poisoning. Eood poisoning is poisoning by germs and their poisonous 
products, which are not commonly true ptomains or special chem- 
ical substances (alkaloids) found in putrefying animal or vegetable 
substances. 

Then again the term ptomain poisoning is applied so frequently 
and with such disastrous consequences to acute organic abdominal 
diseases, as appendicitis and gall-stones, that it should be abandoned. 
When fever is present, in most instances, the case is not one of food 
or ptomain poisoning. 

Food poisoning includes poisoning by meat, fish, lobsters, crabs, 
clams, mussels, snails, cheese, ice cream, cream, milk and its prod- 
ucts, potatoes, canned meat, and vegetables. 



182 POISONS AND ANTIDOTES— FOOD POISONING 

As the poisons are all formed by the growth of bacteria, and as 
such growth occurs more readily in warm weather, it follows that 
food poisoning usually is seen in summer. Again, cooking will gen- 
erally prevent poisoning, but not in some cases, for while cooking 
will kill the germs it does not always destroy the poisons produced 
by them. Some of the fatal cases of meat poisoning have followed 
the eating of cooked meat. Moreover, bacteria find their way into 
cooked food, and thus form violent poisons. This applies particu- 
larly to fish, lobsters, crabs and oysters, which should never be eaten 
later than twenty-four hours after cooking, even when kept on ice. 
They should be cooked alive or as soon as dead, and eaten as soon 
as cooked. Shell fish should be killed by cooking. 

Meat Poisoning. — Meat is poisonous when derived from dis- 
eased animals or when kept too long. Beef from cows which are 
slaughtered because of disease of the intestines or udder, or that 
infection which follows calving, is the most common cause of the 
reported cases of poisoning; also veal from calves, which have had 
navel infection, has been a frequent source of poisoning. It goes 
without saying that no diseased animal is fit for food. In meat which 
is hung too long bacteria breed and form poisons ; but even here the 
meat from healthy animals has not been so commonly the cause of 
poisoning as meat derived from diseased animals. 

Chopped meat, sausages and game are the most common kinds 
of meat which produce poisoning as a result of being kept too long. 
Chopping meat makes it more susceptible to the growth of germs. 
What is called sausage poisoning is due to the growth of a special 
germ in sausages, ham, meat pates and corned beef, where the meat 
is not exposed to the air on account of a covering, as the skin of 
sausages, fat or pates, or ham, etc. The poison formed by this germ 
(Bacillus botulinus) acts on the nervous system {See Symptoms of 
Food Poisoning below). Thorough cooking destroys this poison. 

Fish Poisoxixg. — Poisoning, as from meat, is due to germs in 
diseased fish, or to those which grow in fish after cooking. 

Oysters growing in water defiled by sewage become infected and 
convey the bacteria of typhoid fever, dysentery, and diarrheal dis- 
eases, and rarely Asiatic cholera (in countries where the disease 



FOOD POISONING 183 

exists). Poisoning is most apt to occur from raw oysters, but as 
oysters are not cooked long, there may be danger in eating cooked 
oysters grown in contaminated water. One should always know the 
habitat of oysters and clams before eating them. Then it is said that 
all oysters are diseased in summer (Bardet). The writer has been 
in the habit of eating oysters from the bed during the summer in 
many places, and without harm, but it is a good rule to avoid the 
bivalves in this season. 

Cheese Poisoning. — Many cases of severe poisoning from cheese 
have been reported. The germs, producing the poison, originated 
from the cow and in most cases probably found their way into milk 
from the intestines of the cow in manure. It has been indeed esti- 
mated that as much as ten tons of manure are daily consumed in 
milk in one of the large cities of the world. 

Germs multiply in milk products, even in ice cream when kept 
at the lowest temperatures. Besides the dangers of chemical poison- 
ing (germ-made) from cheese, ice cream, and milk products, special 
diseases are frequently communicated to man by milk. Thus a 
quarter of the tuberculosis in children is derived from cow's milk, 
the germs escaping from the cow chiefly in manure which con- 
taminates milk, while thousands of cases of typhoid fever, diphtheria, 
and scarlet fever have originated from milk in one city alone during 
the past few years. In these cases the milk has become contaminated 
by human carriers of these diseases. The only sure means of pre- 
venting such is proper heating or cooking of milk. 

Potato Poisoning. — Many outbreaks of poisoning from both 
new and sprouting potatoes have been recorded. There is a poison 
(solanin) which sometimes is formed in badly sprouting potatoes, 
and it is most abundant in the peel. More often the poisoning in 
man has been traced to germs introduced by cooks in handling cooked 
potatoes. 

Potato poisoning may be prevented by not using old sprouting 
potatoes and by always peeling them and carefully removing the 
eyes and sprouts before boiling them ; also by not keeping them long 
in warm weather, after they are cooked, and especially by enforcing 
cleanliness in those who handle cooked potatoes. 



18-i POISOXS AXD AXTIDOTES— FOOD POISOXIXG 

Potato salad has been a frequent source of poisoning. 

Caxxed Food. — Canned meat, fish, and vegetables have often 
caused poisoning, owing to the development of germ poisons through 
imperfect heating or sealing of the can ; in such cases the top of the 
can usually bulges from accumulation of gas (blown can). In many 
cases the meat was diseased or putrefying before being canned. 

Vegetables used for salads directly from the can, instead of being 
recooked as they should be, have been responsible for most of the 
cases of poisoning. Cooking will destroy many of these poisons. 
Considering the enormous amount of canned food consumed the 
occurrence of poisoning from the same is rare. Xo blown can 
should ever be used. 

Symptoms of Food Poisoning. — The sudden illness, at about the 
same time, of a number of persons who have partaken of the same 
food constitutes the chief basis for the diagnosis of food poisoning — 
particularly when the kind or character of the food warrants 
suspicion. 

An interval of two to twenty-four hours may elapse before symp- 
toms appear after the poisonous food has been taken, but sometimes 
this period has been as long as one to two weeks. In the latter case, 
owing to the small number of germs swallowed, or to the fact that 
not much germ poison was present in the food, time is required 
for the poison to be formed through the growth of germs in the 
patient. This corresponds exactly to the period of development of. 
any contagious disease after exposure to the same. In most instances 
a person swallows the germs along with much ready-made germ poison 
so that symptoms appear as rapidly as after the taking of any other 
chemical poison. 

The symptoms form two groups : 1. More often poisoning begins 
with violent vomiting and abdominal pain and diarrhea ; there maj 
also be headache, cramps in the muscles, thirst, dilated pupils, and 
even delirium. Marked prostration, muscular weakness, pale clammy 
skin, with weak pulse and cold hands and feet, are commonly seen. 
Various forms of rashes on the skin are frequent. 2. In poisoning by 
sausage, canned vegetables, corned beef, ham, and cheese, the diges- 
tive symptoms just described may be absent and nervous symptoms 



FOOD CONTAINING PARASITES 185 

may predominate as follows : In these cases there are disturbance of 
vision, drooping of the eyelids, dryness of the mouth, difficult swal- 
lowing, loss of voice, obstinate constipation, and difficulty in passing 
urine. Death may occur from general paralysis. 

Treatment for Food Poisoning. — The treatment of food poison- 
ing is similar to that already described for poisons generally, i.e., to 
empty the stomach and bowels and then stimulate the heart, respira- 
tion, and nervous system. 

It is best to procure medical aid, if possible, to wash out the 
stomach. If vomiting occurs, it is not necessary to use an emetic, 
but the patient should be encouraged to swallow all the lukewarm 
water possible and then tickle the back of the throat so as to vomit 
it up again. The same process should be repeated a number of 
times and the result will be almost as effective as though the stomach 
had been washed through a tube. 

A tablespoonful of salt or mustard in the water should be given 
if vomiting is not free. Then the bowels should be emptied by 
enema, if there is much vomiting, or by giving two or three compound 
cathartic pills. For the general depression the patient should be 
kept in bed surrounded by hot water bottles and the advice given 
under Stimulation should be followed. 



POOD CONTAINING PARASITES 

The most important of the parasites found in food in this country 
are the tapeworm and trichina. The hookworm was supposed to enter 
the body in food or water but it is now known that the skin is the 
chief, if not the sole, portion of the anatomy through which it gains 
entrance into the body. The guinea worm is exceedingly rare in 
the United States, although common in Africa and the East Indies. 
It enters the body in food and finds its way to the skin of the foot 
or ankle, usually, where it forms a blister which breaks and leaves 
the worm at the bottom of a small ulcer. The worm then discharges 
its young and leaves the individual. The worms are solitary and 
twenty to thirty inches long. 



186 POISONS AND ANTIDOTES— FOOD POISONING 

TAPEWORM 

Beef and, less commonly, pork tapeworms attack men. Tape- 
worm is caused by eating raw or imperfectly cooked "measly" beef 
or pork. If raw, measly beef is very finely minced, or the juice 
from the same is strained, the danger of tapeworm is everted. 
Measles are embryo tapeworms, called from their appearance "blad- 
der worms." In from six to ten weeks after entering the intestine 
of man these bladder worms become full grown and measure from 
six to twelve feet (pork tapeworm) to fifteen to twenty feet (beef 
tapeworm) in length. They are divided into white, flattened joints. 
The head is of the size of a pinhead, the neck is not much thicker 
than a thread, but the middle and lower part of the body is from 
one-fourth to one-half an inch wide. The bladder worms inhabit 
chiefly the muscles of the jaw in beef where they should be found 
and condemned by inspectors ; the bladder worms in pork are easily 
seen on the under surface of the tongue. 

Symptoms. — The symptoms alone are not sufficiently character- 
istic to enable a doctor to make a diagnosis of tapeworm. Nausea, 
colic, and diarrhea are most common ; sometimes there is anemia. 
There may be a ravenous appetite, and patients often are much wor- 
ried and depressed if they know they have tapeworm. Headache, 
emaciation, itching, loss of appetite and constipation are sometimes 
seen. 

It is quite probable that in most cases there are no symptoms 
and that the discovery of the segments of the worm, which look 
like flat portions of macaroni, are the first signs of the disease. They 
are the only positive signs, together with the passage of eggs. The 
disease is not dangerous and is susceptible of complete cure. 

Treatment. — For two days v the patient should take only milk or 
broths, and on the third day nothing but water, which may make 
the worm loose his hold on the intestine. Castor oil, three table- 
spoonfuls, should be taken on the afternoon of the first two days, 
and a tablespoonful of Epsom salts on the evening of the third day. 
On the morning of the fourth day one drachm of oleoresin of male 
fern is given in syrup, and the same dose repeated one hour later. 



FOOD CONTAINING PARASITES 187 

The patient should remain quiet in bed to avoid nausea. One hour 
after the second dose a heaping tablespoonful of Epsom salts should 
be taken in a glass of water and, if this does not move the bowels 
within an hour, a second dose of salts is desirable. 

The patient should sit on a chamber half full of water at body 
temperature, so that the worm may be passed without being broken. 
Unless the head comes away the worm will grow again. If the worm 
is hanging from the bowel, an injection of soap-suds should be given 
to dislodge it. 

The tapeworm should never be dragged out by force as it will 
break. There is danger that children with tapeworm may convey the 
eggs of the worm, escaping from their bowels and soiling the skin 
about these parts, to their mouths in sucking their fingers. In that 
event the immature worms developing in the intestine may be carried 
to various organs of the body and threaten the child's life. 

Pumpkin seed is very efficient in killing tapeworm while harm- 
less to the patient. The seed should be thoroughly pounded into a 
pulp and soaked in water twenty-four hours. They are given mixed 
with sugar or syrup on an empty stomach in the morning. The dose 
for an adult is four ounces, for a child one or two ounces. An hour 
after the dose of pumpkin seed an adult should take three table- 
spoonfuls of castor oil, a child one tablespoonful. 

Measures for preventing tapeworm include the burning of the 
tapeworm from the human being, the efficient inspection of meat, and 
proper cooking of pork and beef, in order to kill any parasites. 

There are many other efficient and powerful drugs for destroy- 
ing tapeworm. They are not safe unless used according to a doctor's 
orders and for this reason, and because mucus and other matters 
contained in excrement are often taken for worms, it is always best 
to consult a doctor. 

ROUND WORMS 

(Ascarides) 

The large round worm (Ascaris lumbricoides) is the most com- 
mon intestinal parasite attacking man and is found more often in 
children and in the insane. Its eggs may leave one person and enter 



188 POISOXS AXD ANTIDOTES— FOOD POISOXIXG 

the mouth of the same individual, or another, and develop into new- 
parasites without the intervention of another host, as in the case of 
tapeworm. 

Eound worms inhabit the upper part of the bowels. They are 
from four to ten inches long, reddish or yellow-brown in color, and 
pointed at both ends. One female may produce sixty million eggs; 
these are minute, oval, and reddish brown in color. They occur in 
great numbers in the excrement of the host — as many as three thou- 
sand have been counted in a piece of human excrement no bigger 
than a grain of wheat. Tour ridges run the length of the worms; 
those on each side are brownish, while a whitish ridge is seen on the 
back and belly. In rare instances the worms may find their way into 
the stomach, throat, ear, nose, liver, and lungs. 

The mode of entrance of the eggs into the body is somewhat 
obscure. The mouth is the probable gateway. Children are more 
prone to worms because more unclean in their habits. They suck 
their dirty fingers, after scratching themselves about the exit of their 
bowels, and in this way return to their mouths the eggs which have 
escaped from their intestines. The eggs of the round worm may be 
taken into the mouth in impure drinking water, or on uncooked, 
green vegetables or fruit, especially if contaminated with human 
excrement. 

Xo person who has worms should be permitted to handle cooking 
or eating utensils or food. 

Symptoms. — One would suppose from hearing the opinions of 
many mothers that worms and teething together accounted for the 
major part of infantile illness. Both are greatly overrated as sources 
of disease. Unless round worms are present in considerable numbers 
it is probable that they will produce no symptoms in robust subjects. 
The only certain proof of their presence in the human body is their 
appearance in the excrement or vomited matter. 

Among the more common symptoms suggestive of worms are the 
following: irritability, twitching, fidgets, grinding the teeth when 
asleep, picking the nose, fever, convulsions, irregular or ravenous 
appetite without proportionate gain in weight, foul breath, constipa- 
tion, vomiting, or diarrhea. The same symptoms may occur from 



FOOD CONTAINING PARASITES 189 

many other causes and therefore may have no connection with 
worms. 

Treatment.' — The child should have only broth or milk for twenty- 
four hours and then, before breakfast, the nuidextract of pink-root 
and senna should be given — one-half teaspoonful for a child of two 
years ; one teaspoonful for a child of four to ten years ; two teaspoon- 
fuls for an adult. The dose may be repeated two or three times 
during the day, if the bowels do not move freely, and the medicine 
may be given on two or three occasions until the worms are expelled. 
It is well not to repeat the dose on successive days but to give the 
child a day or two of rest from the previous dosing, before beginning 
the treatment again. 

Great cleanliness should be enforced as to washing the parts 
about the anus and the hands, after every movement of the 
bowels. 

The excrement containing worms or eggs should be burned. 

PINWORMS— SEATWORMS— THREADWORMS 

(Oxyuris vermicularis) 

These are minute threadlike worms, from one-seventh to two- 
fifths of an inch long. They live in the lower part of the bowels. 
They may be seen coating the excrement, or clinging to the exit of 
the bowel or neighboring parts. They are more likely to escape 
during the night and may be found on the sheet. 

The eggs remain in the female worms until they escape from the 
body but scratching may crush the worms, and the eggs may get under 
the finger nails and are conveyed to the mouth, when they may rein- 
fect the patient. This may all occur during sleep. 

Pinworms are more common in children and in the insane. 
There is always great itching about the bowel during the night, 
and scratching occasions redness, swelling and inflammation in this 
part. In girls the worms may wander into the vagina, or front 
passage, and lead to inflammation, with swelling and discharge from 
the sexual organs. This local inflammation may also induce general 
irritability, sleeplessness, loss of appetite, anemia, fainting, bed- 
wetting, and masturbation in children. 



190 POISONS AND ANTIDOTES— FOOD POISONING 

The worms may enter the mouth in water or upon raw vegetables 
or fruit. 

Treatment. — Injections into the bowel are usually sufficient to 
remove pinworms. Each morning the bowel should be washed out 
with cool water and Castile soap, lying the child with hips raised 
on a pillow, so that the water may now as far back as possible into 
the bowel. In older children a better position consists in lying on 
the face (turned to one side), chest and knees. The patient should 
kneel on the bed, with the head and chest also pressed on the bed for 
support, so that the body slants downward and forward and the hind 
quarters are raised high from the bed. 

After giving the enema the parts about the bowel are washed 
well with soap and water, and dried. Then carbolized vaselin or 
boric acid ointment is applied to relieve itching. It is well also to 
give children each morning a dose of pink-root and senna, as advised 
for round worms, for several days — in order to expel worms from 
the higher parts of the bowel not reached by the injections. 

Whenever the bowels move the various parts thereabout should 
be thoroughly washed, and towels, bed clothes, and night garments 
should be boiled, in order to prevent further infection with the 
parasites. 

Children's toys should be burned, carpets cleaned, and floor and 
furniture washed to avoid a return of the disease through eggs 
attached to these objects. 

When the pinworms are not readily expelled by simple soapsuds 
injections, these may be followed by an injection of a strong solu- 
tion of common table salt and water. This should be retained in the 
bowel as long as possible, a folded towel being pressed against the 
back passage to keep the injection in. The injections should be 
repeated each day for ten days. 

TRICHINIASIS 

This is a very painful and dangerous disease caused by the 
presence in the muscles and other tissues of little worms which 
are eaten in raw or partly cooked pork, ham, bacon, or sausage. They 
may also occur in uncooked or partly cooked salted or smoked pork. 



FOOD CONTAINING PARASITES 191 

The disease is only common among Germans since they often eat 
raw ham and sausage. 

The diagnosis is very difficult in single cases. In autopsies on 
persons dying of other diseases in Buffalo, over five per cent, were 
found to have the worms in their muscles. 

Symptoms. — Nausea, loss of appetite, colic, and diarrhea occur 
within a few days of eating the infested pork, but these symptoms 
are sometimes absent. 

From seven to ten to fourteen days after eating the trichinous 
pork fever develops with pain, swelling, stiffness and tenderness 
in the muscles, so that the disease is sometimes thought to be rheu- 
matic fever but the joints are not swollen. There may be pain in 
swallowing and chewing. Swelling of the face, and especially about 
the eyes, is very suggestive of the disease. Difficulty in breathing, 
hoarseness, and sweating, are frequent. 

Delirium, bronchitis, pleurisy, and pneumonia are among the 
more severe complications. 

When a number of persons come down with an apparent typhoid 
fever, with the painful symptoms noted, after a German birthday 
Fest trichiniasis should be suspected (Osier). Examination of the 
remains of pork, ham, or sausage left from the party, and of the 
excrement and muscle of the patients for the worms, may decide the 
diagnosis. Examination of the patient's blood for changes is also 
important. 

Treatment. — There is no special treatment other than to empty 
the bowels, in persons who have been poisoned by eating meat. Fol- 
lowing the use of two two-grain doses of calomel two hours apart, 
for an adult, a tablespoonful of castor oil or Epsom salts in a 
glass of water should be given four hours after the second dose of 
calomel. 

The mortality is from one to thirty per cent, in different epi- 
demics. The outlook is best in children. Many unrecognized cases 
are classed as typhoid fever or rheumatism. 

Preventive Measures. — The moral is to cook pork thoroughly. 
The boiling of sausages for fifteen minutes before frying them is 
advisable. 



192 POISOXS AXD ANTIDOTES— FOOD POISONING 

HOOKWORM DISEASE 
( A nkylostomiasis) 

The hookworm has, from the most ancient times, probably been 
responsible for an enormous amount of sickness all over the world, 
but it is comparatively recently that its significance has been fully 
appreciated. 

There are two varieties of hookworms, the American variety 
being first described by Stiles of the United States Agricultural 
Department, in 1901. 

The disease exists in most tropical lands and also to a considerable 
extent in temperate regions, as is shown by its great prevalence in 
the following countries : The population is affected by hookworm in 
Porto Rico to the extent of 90 per cent., while 60 to SO per cent. 
are infected in India, about 15 per cent, in the Philippines, and in 
the whole United States from 20 to 80 per cent, of persons harbor 
the hookworm, the disease being particularly common in the Southern 
states. A considerable proportion of adult hosts of the hookworm 
may, however, appear healthy. 

The hookworm belongs to the same family as the common round 
worm (Ascarides) of children. It is very slender, from one-sixth to 
one-third of an inch in length (the longer the female) and the mouth 
is provided with sharp teeth which enable it to hook onto the inside 
of the bowel. The eggs are microscopic, and swarm in the bowel 
discharges of the patient, as many as four million having been found 
in one movement. 

The eggs begin to divide into segments in the bowels of the 
patient and this goes on outside the body in the ground with the 
formation of the immature worms (larvae). The eggs hatch best in 
earth at the temperature of 70° -90° U. but may withstand freezing, 
and immersion in water for months. Under favorable conditions 
the young worms may be ready to enter the body within four or 
five days after the eggs are discharged from the bowels of a patient. 
The worms may be taken into the mouth in water or on soiled fingers, 
but the common mode of entrance is through the skin. The young 
worms bore their way through the skin of the feet and legs of the 



FOOD CONTAINING PARASITES 193 

barefoot; and through the hands and arms of miners and gardeners. 
The worms are carried through the veins to the heart and lungs and 
thence find their way up the windpipe into the throat where they pass 
into the stomach and fasten onto the first part of the small intestines 
and suck blood from the host. 

The worms not only remove blood directly, but they secrete a 
poison which tends to destroy the blood in the patient's body and 
lessens its clotting capacity. The patient may also suffer from 
blood poisoning from bites of the worms becoming infected with germs 
in the bowels. 

Symptoms. — These are seen more often in children and young 
adults. Pallor, weakness, stunted growth, lack of energy, laziness, 
"a dull, blank stare," pot belly, loss of appetite, nausea, pain and 
tenderness in the belly, colic, diarrhea, and general ill health without 
actual disease, are characteristic. 

The laziness of the South and Porto Rico is attributed to hook- 
worm. The notorious clay eaters of the South who eat earth, clay, 
starch, hair, etc., have a perverted appetite because they are suf- 
ferers from hookworm. 

Ground itch is a skin eruption caused by worms entering the 
skin and is especially common as small blisters, which later contain 
matter or pus under and between the toes. In severe cases patients 
may become bedridden with great weakness and pallor and swelling 
of the feet and other parts of the body. 

Diagnosis. — The previous occurrence of ground itch, and the 
presence in the patient of pallor, and weakness, usually suffice in 
affected regions to enable a diagnosis to be made. The presence of 
blood in the bowels is significant of hookworm. If a portion of 
bowel discharge is placed on a piece of white blotting paper and, 
after an hour or two a rusty stain appears about it, we have a simple 
test for blood. The positive test is the discovery of eggs in the 
bowel discharges, two or three teaspoonfuls of which should be 
collected in a wide-mouthed bottle for microscopical examination 
by a doctor. 

Treatment. — The rules of the Porto Rico Commission follow. 
The patient should take a tablespoonful of Epsom salts in a glass of 



194 POISONS AND ANTIDOTES— FOOD POISONING 

water before eating in the evening. At 6 a. m. next morning one- 
half the dose of thymol in capsules is taken. At 10 a. m. another 
dose of salts is taken. At 8 o'clock the next morning the other half, 
of the dose of thymol is taken. The dose of thymol varies from 
seven grains, for children under five years of age, to sixty grains for 
adults. No wine or other form of alcohol should be taken while the 
medicines are acting. Come for more medicine until the doctor says 
you are cured. Have a privy in your house. Use the privy and 
do not move the bowels on the surface of the ground. Do not walk 
barefooted, so that you may avoid contracting the disease in your feet. 
Wear shoes and you will never suffer from anemia. 

In infected regions it is well also to boil drinking water and 
to be particular about having the hands clean before eating. The 
bowel discharges should be covered in privies with milk of lime made 
by adding one part of freshly slaked lime to four parts of water. 

In Porto Rico the Commission's work in fighting hookworm has 
reduced the mortality from forty-two to twenty-one deaths per 
thousand annually. 



CHAPTER XI 

MENSTRUATION AND ITS DISORDERS— DISEASES OF WOMEN 
—CHANGE OF LIFE 

Menstruation : normal, painful, absence of, arrested, scanty, delayed, and 
excessive. Leukorrhea. Signs of pregnancy. Miscarriage. Death of 
child in the womb. Change of life. 



MENSTRUATION 

Menstruation consists of a flow of blood and mucus from the 
womb for an average period of five days, but varying normally in 
different women from two to ten days. These periods occur at inter- 
vals of twenty-eight days usually, but exceptionally the intervals vary 
from twenty-one to thirty days. The reasons for, causes, -and uses 
of menstruation are still matters of theory. Animals, with the 
exception of the higher apes, have only a discharge of mucus at 
similar periods. 

The possible child-bearing period of women corresponds usually 
to the time from the appearance of the first menstruation to its 
cessation at the "change of. life," or menopause. 

The usual time at which menstruation or the "unwell" periods 
begin is from fourteen to fifteen in the United States (exceptionally 
from nine to eighteen years), and they continue till forty-two to 
fifty years. In the tropics menstruation begins on the average at 
ten to eleven years ; in the Arctic regions at sixteen ; while the Slavs 
menstruate first at fourteen, and the Hungarian Jews at thirteen. 
This is the period of puberty, or the age when the sexual organs 
develop. 

Puberty should really be considered to extend from the begin- 

195 



196 DISEASES OF WOMEN— CHANGE OF LIFE 

ning of menstruation to the twentieth year. During this time the 
changes characteristic of the feminine sex appear, as enlargement of 
the breasts, broadening of the hips, general rounding of the outline 
from the deposit of fat under the skin; also growth of hair at the 
lower part of the abdomen and under the arms. 

There is a popular misapprehension that menstruation is the 
time at which conception occurs. This is not the case, although 
conception is most apt to take place during the eight days following 
the end of menstruation. Conception occurs when the ovum or egg 
escapes from the ovary (ovulation) and passes down through the 
fallopian tube into the womb and unites with the male seed, following 
sexual intercourse (during which some twenty-six million male seed 
may be liberated) . 

But while the escape of the ovum or egg (one, or occasionally 
two in twins of opposite sexes) from the ovary usually takes place 
at the same time as menstruation, this is frequently not the case 
and conception may happen at any time. Conception occasionally, 
is seen in women who have not menstruated for months, as while 
nursing a baby, or even after the final cessation of menstruation at 
the "turn of life." Stated briefly, ovulation is not always synchronous 
with menstruation. 

The average possible child-bearing period is thirty years, or 
from fifteen to forty-five. The earliest pregnancy on record was in 
a girl of eight, and the oldest woman known to have borne a child 
was seventy, and these dates approximately correspond to the earliest 
and latest unwell periods recorded in medicine. Pregnancy in a 
woman over sixty is rare, but many instances have been recorded 
between fifty and sixty. Menstruation sometimes appears in women 
after both ovaries have been removed. 

There is a regular cycle of health in women, the acme of which 
is reached a few days before menstruation, and following this is a 
period of more or less mental and physical depression, during men- 
struation, and a gradual improvement in health after its cessation. 

Symptoms of Menstruation. — The first appearance of menstrua- 
tion in the girl may be heralded by some irritability, restlessness, 
feeling of weight in the loins and headache, but more severe trouble 



MENSTRUATION 197 

Is not present unless there is some displacement of the womb, or 
disease. 

Symptoms ordinarily occurring in women should also be very 
slight, if the general health is good, unless there is some disorder of 
the sexual organs. Among the more common symptoms are the 
following: some swelling and soreness of the breasts with slight 
enlargement of the tonsils and thyroid gland, a feeling of being 
hot or chilly, some frequency in urination, heaviness in the region 
of the womb and loins, nausea, headache, dizziness, and cold hands 
and feet. 

Women are more subject to colds at this time. The character 
of the patient is also altered so that she may be irritable, depressed, 
quarrelsome or even fierce. No woman exhibits all these symptoms, 
but some of them are common. So much is the character changed 
that it has been found that most crimes of women are committed 
during menstruation — including suicide, and the more terrible ones, 
down to shoplifting among the prosperous. 

At the beginning of menstruation there is a white discharge of 
mucus from the private parts, followed by blood, which reaches the 
maximum on the second day, lasts several days, and gradually ceases 
— to be replaced by a white flow of mucus for a few days longer. The 
amount of blood lost varies from two to ten ounces, usually from six 
to eight. It is often measured by the number of napkins worn, which 
average fourteen in number, but this is a very uncertain criterion. 

When the menstruation begins late in life (after fifteen), it often 
ceases early — at the age of forty-five. On the other hand when it 
begins earlier it commonly lasts longer — till the age of fifty or so. 
Menstruation usually ceases (not always) when a woman becomes 
pregnant and begins again soon after the birth of a child — unless 
the mother nurses her infant, when it is ordinarily delayed until 
after weaning time. Occasionally women become pregnant during 
the period of nursing, although not menstruating. 

When the womb is removed, of course bleeding from it is forever 
over, and usually with the removal of both ovaries menstruation 
ceases and an artificial "change of life" begins. 

Menstruation may sometimes persist, however, after the latter 



19S DISEASES OF WOMEX— CHAXGE OE LIFE 

operation. It is somewhat difficult to define what is abnormal men- 
struation, as some women flow more and longer than others, or have 
more pain, or may be somewhat irregular. Severe pain is always 
abnormal, and also flowing above the average, or rather the patient's 
average. 

Care of Normal Menstruation. — In order that menstruation may 
be normal, girls must be cared for from early age. Attention to 
the general health is the chief thing until the beginning of men- 
struation (see Personal Hygiene). Then the girl should be prepared 
for the occurrence as a natural event in her life. She should be 
made to rest, although not necessarily in bed, during the period and 
should not tax herself in any way. by study, exercise or amusement, 
and the diet should be simple during the time of menstruation. 
Special care of the girl up to her twentieth year, or during the age 
of puberty, is also advisable to avoid future menstrual troubles. 
She should lead a quiet life, have a plain diet, and not overtax her 
strength by amusements, study or work, and as the sexual life has 
begun, care should be taken in the selection of her books, associates, 
theatrical amusements, etc., so as to avoid undue stimulation of the 
sexual functions. Pregnancy is inadvisable before the twentieth year 
because the muscles are undeveloped, the bony outlet has not reached 
its full size, and because the girl has not attained the full mental, 
moral, and physical development to care for a child. The grown 
woman should free herself from more taxing affairs for two days 
before menstruation and rest part of the day on a bed while un- 
well. 

A warm bath may be taken for two minutes daily, unless it causes 
too much flowing. When the flowing is scanty, a hot sitz bath is 
useful. Cold baths during menstruation are to be avoided. The diet 
should be simple. The use of a hot water bag over the lower part of 
the abdomen often relieves discomfort. The taking of alcohol to 
relieve pain is unwise as the habit is all too readily acquired in the 
case of some, and it is impossible for the individual to know that she 
is not in this category without experimenting. Constipation is to be 
avoided as it increases congestion about the womb. When she feels 
she is going to be unwell a woman should take a Seidlitz powder. 



MENSTRUATION 199 

or one-half bottle of magnesium citrate or other laxative, before 
breakfast. A woman should loosen her corsets, when unwell, to 
avoid compression of her abdomen. 

Painful Menstruation (Dysmenorrhea).— The pain may be mild 
or excruciating and in the back, loins, or low down in the abdomen ; 
and it may be sharp, dull, dragging, or cramplike. It may come on 
before or during menstruation, and may cease or increase with the 
flow. It may last only a day or two, or continue through the whole 
period. There is always a certain amount of congestion preceding 
normal menstruation. 

Pain may be caused by abnormal congestion, by inflammation of 
the womb or neighboring organs, and by various diseases noted below. 
The pain may be so severe that the general health suffers, and 
nausea, faintness, and nervous symptoms (as hysteria) produced by 
the pain may occur. On the other hand, nervous diseases, as hysteria 
and neurasthenia, may lead to great suffering. 

The presence of much bleeding and clots may cause severe labor- 
like pains in their expulsion, and the same applies to the existence 
of retained fluid, or membranes in membranous inflammation. Ob- 
struction to the blood vessels in displacements may increase the con- 
gestion, and malformations, and obstruction to the outlet of the 
womb may lead to pain from retained secretion. 

In pain from inflammation of the ovaries, there are tender breasts 
and pronounced nervous symptoms. The suffering begins before the 
menstruation, the pain extends down into the thighs, and there is 
tenderness over one or both ovaries, which are situated low down in 
the abdomen about two inches either side of the middle line. Tumors 
of the womb cause painful menstruation by producing displacement 
and increasing the congestion. 

The causes are either local or general. Sometimes when no 
local cause can be discovered by a physician painful menstruation is 
one of the first signs of a nervous or neurotic temperament. To 
avoid painful menstruation the care of the young girl already advised 
above and also discussed under sexual hygiene, should be followed. 
Any causes which excite the sexual functions unduly will produce 
congestion and painful periods. Thus excessive sexual intercourse, 



200 DISEASES OF WOMEN— CHANGE OF LIFE 

masturbation, books, plays or associates stimulating the sexual appe- 
tite, or poor general health, may occasion dysmenorrhea. 

Treatment of Painful Menstruation (General Measures). — When 
there is severe pain during menstruation a doctor should always be 
consulted. Treatment which is not based on the causes present in the 
particular case may be futile or harmful in wasting time and so lead 
to breaking down of the general health. Only when a doctor cannot 
be had are the following suggestions to be followed. 

The patient subject to painful menses should stay in bed from 
the onset. She should take a laxative, as advised above, and abstain 
from tea, coffee, alcohol, and meat. The drinking of six glasses of 
water daily, chiefly between meals, will be of advantage. A good 
masseuse can often relieve congestion and bring relief by general 
and abdominal massage given once daily during menstruation for 
one-half to three-quarters of an hour. Sexual intercourse in the 
married should be omitted until the patient no longer has painful 
periods. Husband and wife should occupy separate beds or rooms. 

Heat is most efficacious. Heat is utilized by the patient in taking 
hot sitz or full baths for fifteen minutes once daily while the pain 
lasts. This is not advisable if there is much flowing, but such is not 
present in most cases of painful menstruation. Then, in the case of 
married women, a douche as hot as possible, while lying in the bath 
tub on the back with the legs drawn up, will be of service, when 
taken once daily between the periods. As much as four quarts of 
water should be used at a time from a fountain syringe. The same 
posture may be taken on a bed or table by using a douche pan or 
Kelley pad to catch the escaping water. Unmarried women should 
only take such douches by a doctor's advice. The employment of a 
hot water bag over the lower abdomen is also of value. 

Hayden's viburnum compound is an old, valuable and harmless 
remedy given in teaspoonful doses once hourly in hot water, until 
the pain is relieved or until three doses are taken. When the nervous- 
ness is pronounced the patient may take ten grains of strontium 
bromid, together with a teaspoonful of tincture of valerian, in one- 
half glass of water, three times a day. 

Absence of Menstruation (Amenorrhea). — Absence of menstru- 



MENSTKUATION 201 

ation may be due to many causes; these are local or general. But 
general causes may lead to local, as will be seen. In the case of 
absence or faulty development of the sexual organs menstruation 
will probably never occur — this is a very rare condition, however. 

Various diseases give rise to wasting of the sexual organs. In- 
flammations of the womb after labor may end in wasting of the 
womb and permanent cessation of menstruation. A similar condition 
occasionally follows such acute diseases as typhoid, scarlet fever, and 
diphtheria, but in these cases the menstruation is usually resumed 
again. 

In many chronic diseases the stopping of menstruation is a 
compensatory provision of nature to save loss of blood, as in tuber- 
culosis, diabetes, Bright's disease, heart disease, malaria, and anemia, 
although sometimes in anemia there may be excessive flowing. The 
cessation of menstruation is not a cause or common sign of tuber- 
culosis* as thought by the laity. 

If the flow never appears in a young girl, and yet she has all 
the other sensations peculiar to menstruation, she should be examined 
by a physician to determine whether there is any obstruction to the 
escape of blood. This is rare, and usually the late appearance of 
menstruation is due to poor development of the sexual organs from 
anemia and general poor health. 

Sometimes an apparently healthy girl may menstruate regularly 
at first and then stop. In many of these cases the hygiene is imper- 
fect and the girl is devoting too much energy to amusements, social 
entertainments, or to excessive study or work. There are instances 
when menstruation ceases in robust young women with normal sexual 
organs, without apparent cause, and may only return after marriage. 
Pregnancy has occurred in these in the entire absence of men- 
struation. 

The occasional omission of a period during the first year of 
menstruation is normal but after that time it should appear at regular 
intervals. 

Nervous shocks frequently lead to cessation of menstruation, as 
great emotion, fright, grief, or anger. Anxiety lest pregnancy occur, 
in the newly married or in the woman who has immorally exposed' 



202 DISEASES OF WO ME ]\ T — CHANGE OF LIFE 

herself to the possibility of pregnancy, may thus cause a delay in 
the monthly flow. Radical changes of climate and surroundings may 
stop the monthly flow for several periods in women immigrants 
seen in this country. 

Chill, as exposure to cold, sitting on damp ground, wearing wet 
clothes, or bathing in cold water at the beginning of menstruation 
may arrest it. Exhausting occupations, overwork or study, insuffi- 
cient food, fresh air and exercise favor amenorrhea. Also premature 
social excesses in the young. 

Absence of menstruation is often accompanied by all the usual 
symptoms except the flow and there may also be ringing in the ears, 
defective sight, sweating and various skin eruptions. 

When menstruation has once become well established its cessation 
is due more commonly to anemia and debility in underfed and over- 
worked young women. Pallor, constipation, fluttering of the heart, 
dyspepsia and gas in the stomach or bowels, fainting at slight provo- 
cation, and cold hands and feet are among the common complaints 
in this condition, together with a feeling of weight in the lower 
part of the abdomen and a white or yellowish discharge from the 
private parts. 

Treatment of Amenorrhea. — Treatment consists in relieving 
constipation and taking a modified 5-grain Blaud's pill (of iron) 
three times daily after meals for several months, stopping the pill 
for a week, however, each month; also the keeping of early hours 
and securing plenty of sleep, fresh air, exercise, and a simple diet, 
the avoidance of tea, coffee, fried food, cakes, pies, fresh bread, 
candy and sweets, and the relief of the "whites." 

Absence of menstruation in young girls who are pale, thin, list- 
less, and poorly developed, must be treated in the same manner be- 
taking them from school and making them live out of doors on whole- 
some food with four glasses of mixed rich cream and milk daily, at 
breakfast, in the middle of the morning, afternoon, and at bedtime. 
Iron is useful if the doctor finds the patient actually anemic, as 
pallor alone is no sure sign of anemia. 

Beginning Menstruation Suddenly Arrested.— If the monthly 
flow has already begun but is suddenly stopped through exposure to 



MENSTRUATION" 203 

cold, fright, etc., there may be a chill, fever, backache, headache, 
bearing-down pains in the lower part of the abdomen, pain in the 
thighs, and frequent desire to pass water. The patient should take 
a full bath or sitz bath for twenty minutes, as hot as can be com- 
fortably borne, and then go to bed. A teaspoonful of Hayden's 
viburnum compound in one-half glass of hot water may then be 
taken every hour for three doses. If the pain continues, and a 
physician cannot be reached, a suppository containing one-fourth of 
a grain of belladonna extract should be introduced into the bowel 
(rectum). There may be absence of several menstrual periods 
following such an attack. 

Scanty or Delayed Menstruation. — All the symptoms commonly, 
denoting the coming of menstruation may be present and yet there 
may be no flow. During this time there may be pain or a dragging 
feeling low down in the abdomen, back, and thighs, pain and fullness 
in the head, cold hands and feet, and general mental and physical 
depression. In some cases the flow is so scanty that little relief is 
afforded. 

In delayed menstruation, not due to pregnancy, the taking of 
hot sitz baths for fifteen minutes twice daily, and a capsule of 
apiolin four times daily, may rapidly bring on the normal flow. 
Massage, as advised above, may relieve the discomfort. But in some 
women who cannot afford to lose much blood the normal period of 
flow is only two days while in a full-blooded female a flow for ten 
days may not be abnormal. The causes of a scanty flow are the 
same as of complete absence of menstruation, and the treatment 
also. The patient should therefore consult a physician concerning 
her local and general condition. 

In the case of married women, who are subject to scanty flow 
and disagreeable conditions due to congestion at the period, the use 
of douches of water, taken night and morning between the periods, 
as hot as can be comfortably borne, may be of service. The proper 
method of taking douches has been described above. Douches are 
not to be recommended for young unmarried women. 

Flowing, Bleeding, or Hemorrhage from the Womb. — Under this 
heading we will consider two kinds of flowing: (1) excessive bleed- 



204 DISEASES OF WOMEN— CHANGE OF LIFE 

ing at the monthly periods, and I 2 i bleeding from the womb at 
other times. 

The same causes which lead to excessive loss of blood at the 
monthly periods often occasion bleeding from the womb at any time. 
Any condition which brings a greater amount of blood to the womb 
than is natural or alters its structure or the composition of the blood, 
may produce bleeding from this organ. Among the common causes 
are inflammation of the womb, fallopian tubes, and ovaries ; tumors, 
as cancer and fibroid tumors ; displacements, in obstructing the return 
flow of blood ; foreign, bodies, as retained afterbirth ; and general 
diseases, as heart disease, hemorrhagic disorders, scarlet and ty- 
phoid fevers, and malaria. Constipation and tight lacing both may 
interfere with the circulation in the lower part of the abdomen and 
are frequent causes of excessive flowing from the womb ; also harden- 
ing of the arteries in the womb. 

What shall be considered excessive flowing depends somewhat on 
the history of the individual case. In general a menstruation which 
lasts six days, with the use of fifteen napkins, may be considered 
normal. 

Excessive menstruation in girls and young unmarried women is 
commonly due to poor nutrition, debility and anemia and some other 
general or local conditions (other than disease of the womb), even 
appendicitis. Rest in bed for a day or two with attention to the 
oeneral health as advised above may cure the condition, but the 
advice of a doctor is more to the point. The patient will be glad 
to learn that a local examination is not usually required in these 
cases. 

In all cases of undue loss of blood during the periods in married 
women a physician should be consulted to determine the cause, and 
by this means steps will be taken toward remedying the trouble. It 
is most important that women should get professional advice in the 
case of flowing at times other than at their regular periods. Espe- 
cially is this true after the age of thirty-five in married women who 
have even a slight discharge staining the clothing brown, or just 
enough bleeding to soil the clothes between the periods. And again, 
after the completion of the change of life, the appearance of a watery 



MENSTRUATION 205 

discharge and a very little blood at irregular intervals calls for 
immediate professional consultation. 

In fibroid tumors of the womb there are long periods of flowing 
with intervals of freedom from hemorrhage. Fibroid tumor also 
usually appears in women over thirty-five years of age, and while 
not always requiring removal, yet the operation is almost invariably 
successful and without danger in the early stages. 

Irregular bleeding from the womb in young married women, 
especially if there are any signs of pregnancy, as morning nausea 
or vomiting, tenderness and swelling of the breasts, absence of the 
usual regular periods, with perhaps pain in one side of the lower part 
of the abdomen, should cause the patient to seek a physician's advice 
at the earliest moment because such a condition is suggestive of a 
pregnancy in which the child is situated in the fallopian tube, instead 
of in the womb (extra-uterine pregnancy). In these cases an opera- 
tion is absolutely imperative to avoid rupture of the. tube as the 
child grows. This trouble may result fatally, if left alone, but opera- 
tions at the stage described are practically without danger. 

Flowing during the later months of pregnancy, even if slight 
and occasional, is suggestive of a faulty or low position of the after- 
birth or placenta (placenta previa) which is pressed upon by the 
head of the child in the womb and so subjected to injuries. The 
fact of the bleeding should be brought to the immediate notice of a 
physician in order that he may take steps to avert what might be a 
serious hemorrhage at childbirth from tearing away of the placenta 
in the dilatation of the womb. 

Emergency Treatment of Flowing.— It is rare that flowing is so 
excessive during the monthly periods that it becomes dangerous or 
requires immediate treatment to stop it. Such flowing is produced 
by the various causes noted above and should receive proper atten- 
tion and study by a doctor. We will, however, here describe the 
general emergency methods which may be used with ease and safety 
by the patient or attendants to arrest undue flowing from the womb 
from any cause and at any time — when medical attendance is not 
obtainable : — ■ 

Rest in bed with the head low and the foot of the bed raised a foot 



206 DISEASES OF WOMEN— CHANGE OF LIFE 

from the floor (on boxes) is of the greatest importance. The patient- 
must keep as quiet as possible and take a teaspoonful of fluid- 
extract of ergot in one-half glass of water and repeat it in half 
teaspoonful doses at half hour intervals for three doses. If the 
patient is pregnant ergot is not to be recommended. 

The injection into the front passage of six quarts of water, as 
hot as the elbow can comfortably bear, with the patient lying flat 
on her back in bed on a rubber sheet or douche pan, is most valuable. 
The injections should be given with a fountain syringe raised two 
feet above the patient ; and they may be repeated in four hours. A 
teaspoonful of alum added to the last quart may increase the action 
of the injection in stopping the flow. 

In order to stop dangerous hemorrhage, which cannot be arrested 
by the means described, it may be necessary to fill the cavity of the 
front passage, and perhaps the womb, with clean, sterile cheesecloth — 
but this can only be done properly by a doctor. Usually the simpler 
methods will suffice to arrest the bleeding until medical aid can be 
obtained. 

The most dangerous and severe flowing is apt to occur imme- 
diately after childbirth, and this may be best controlled by firm 
pressure on the outside of the lower part of the belly over the womb, 
grasping the womb, if possible, between the thumb and fingers and 
keeping up steady downward pressure for half an hour or so — regard- 
less of the moderate suffering it may cause the patient. The use of 
ergot is of the greatest value here in the doses described above. 

The various causes of flowing noted above should of course be 
avoided. Quiet and rest in bed, with prevention of constipation, are 
the chief aids in cure. 



THE WHITES— LEUKORRHEA 

Leukorrhea, or the whites, consists in a discharge from the private 
parts of women which comes either from the womb or front passage 
(vagina). It is not a disease but a sign of disease of either the 
female sexual organs or of the whole body. When it only appears 



THE WHITES— LEUKORRHEA 207 

for a few days before and after menstruation, during pregnancy, or 
the change of life, it may be regarded as a natural occurrence — pro- 
viding it is not associated with other symptoms of local or general 
disease. 

In ordinary conditions there should be no perceptible discharge 
from the private parts of women and if such occurs — with the 
exceptions noted — it should be regarded as a symptom of general 
or local disease, and a physician should be consulted. 

The discharge is not by any means white, as the common term 
"whites" would suggest, but it may be yellowish, brownish, or 
reddish if mixed with blood, or colorless, like white of egg. It also 
varies greatly in consistency and amount. 

Causes. — Among general disorders causing leukorrhea are : debil- 
ity, anemia, malaria, tuberculosis, and various acute diseases, as 
typhoid and scarlet fevers, measles, and diphtheria. Exposure to 
heat, dampness, and emotional excitement may occasion the disorder. 

The discharge is white or watery, when due to disturbance of the 
general system, whereas in local disease it may be thick and yellow, 
as in pus from a wound. 

Whites is one of the most frequent symptoms of inflammation 
of the womb, tubes, ovaries, and neighboring structures ; also of 
injuries of these organs, as following lacerations occasioned by child- 
birth. It is produced by tumors, displacements of the womb, irritat- 
ing injections, and by too frequent sexual intercourse, etc. In all 
cases of local disease of the sexual organs there are usually other 
symptoms present — as pain in the lower abdomen and back or front 
passage, frequency, and perhaps pain in urination, and often a thick 
and yellowish discharge. Leukorrhea is a common disorder of 
advancing age but should never be disregarded as it may indicate 
the occurrence of a tumor at any time after thirty-five and it may 
then be dark colored, thin, and perhaps foul or blood stained. 

In young children whites may be due to worms, and should 
receive medical attention. As a result of continuous discharge the 
skin about the private parts become much irritated, and itching, 
chafing, rawness, and soreness often eventuate. While a copious 
discharge is a certain drain on the system, yet, if there is general 



208 DISEASES OF WOMEN— CHANGE OF LIFE 

weakness, the "whites" is more than. likely to be the result of the 
general condition rather than the cause. 

Leukorrhea, beginning suddenly and accompanied by frequent 
and painful urination, and swelling and soreness of the external 
parts, is extremely suggestive of gonorrhea, a grave sexual disease 
communicated from man through sexual intercourse. It is sometimes 
seen in babies and little girls who acquire the disease from, towels 
or other objects contaminated with the germs. Patients with this 
trouble should remain in bed, use only hot water to bathe the private 
parts, and take ten drops of tincture of belladonna with one-half 
teaspoonful of sweet spirit of niter in a whole glass of water three 
times daily to relieve the painful urination. The main object should 
be to consult a doctor, however, as gonorrhea is the most common 
cause of .inflammation and abscess of the tubes and ovaries — ulti- 
mately requiring the surgical removal of these organs — if it is 
neglected. 

It will be seen then that like other local diseases leukorrhea may 
be due to many causes, some of which are of the most extreme impor- 
tance and demand the best medical advice. The treatment which 
follows is only recommended w T hen a physician's services are not 
obtainable or for the form occurring in pregnancy. 

Treatment. — The patient should wear a pad of clean absorbent 
cotton over the private parts, held in place by the ordinary unwell 
napkin. Many women believe that covering the passage increases the 
discharge ; this is not so and cleanliness is an important part of the 
treatment. An injection into the front passage of boiled water (four 
quarts), which is just comfortably warm, should be made with a 
fountain syringe once daily or every other day. To the last quart a 
teaspoonful of alum may be added. In case of non-pregnant women 
the water should be as hot as the elbow can bear. The patient 
should lie on her back, on a douche pan or rubber sheet or bath tub, 
to carry off the escaping water. 

Taking a douche sitting on the water closet is not so effective 
but may be done. Itching of the private parts is relieved by the 
injection but, if this is not sufficient, the parts should be bathed with 
a pint of hot water (in which is very thoroughly mixed a teaspoonful 



SIGNS OF PREGNANCY 209 

of diluted carbolic acid solution) and then the parts should be dusted 
with the following powder : — 

Formula for Powder 

Boric acid 1 drachm 

Zinc oxid 3 drachms 

Starch 6 drachms 

Mix and apply with absorbent cotton. 

At other times the parts may be bathed with warm water and 
tar soap and then the powder may be dusted on. 



SIGNS OF PREGNANCY 

Absence of Menstruation Due to Pregnancy.— Pregnancy is the 
more common cause for cessation of menstruation in married women. 
When there is a possibility of pregnancy, delayed menstruation should 
receive no treatment. If the condition is actually one of pregnancy 
there is no drug or other means known to the medical profession by 
which it is possible for a woman to bring on a miscarriage without 
greatly endangering her life — apart from the great immorality and 
crime of the proceeding. The same difficulty of causing a harmless 
abortion, the same danger to the patient's life and the same degree 
of crime obtain if the patient is but a week pregnant. 

Persons who perform abortions are usually as incompetent as 
they are criminal, and blood poisoning and death of the patients 
are not infrequent. The very secrecy required is of itself sufficient 
to prevent the abortionist from giving the patient proper care, even 
if he were competent to give it. There is no justifiable cause for 
interrupting pregnancy save when the condition threatens the moth- 
er's life — which occasionally happens. But in such a case a con- 
sultation of reputable physicians is considered necessary before 
properly deciding upon such a grave and important step. The only 
course for women who fear pregnancy is to wait, and the result will 
be evident in time. A physician should be consulted and he may at 
early date be able to give a probable opinion as to the condition, 



210 DISEASES OF WOMEN— CHANGE OF LIFE 

although it is impossible for him to give a positive opinion before the 
third month and possibly not until the sixth. 

TVomen illegitimately pregnant should either marry, or arrange 
to give birth to a child at full term privately, and prevent the pub- 
licity which ruins the afterlife. There are many societies and chari- 
table institutions which not only assist women in this lamentable state 
but aid in the care and disposition of the child. Here, as in most 
other cases of physical and mental trouble, the advice of a good, 
competent physician will smooth the way and prove of more value 
to the unfortunate woman than anything else. 

Special Symptoms. — Complete cessation of menstruation is the 
rule, although occasionally there may be but a slight amount of 
flowing at the regular period even when the subject is pregnant. , 
Morning vomiting appears often as early as the end of the first fort- 
night and may last until toward the fourth month of pregnancy. 

This vomiting differs from the ordinary kind usually in that, 
after the woman gets out of bed and vomits, she may feel free from 
nausea, have a good appetite and be able to eat as well as usual. Oc- 
casionally there are, however, symptoms common to ordinary indiges- 
tion, as pain in the stomach, gas, nausea, loss of appetite, with 
belching of sour matter, burning in the region of the breast bone, and 
vomiting at various times during the day. 

Changes in the breast are fairly constant. The breasts swell, and 
slight pain or itching are felt in them. The dark area about the 
nipple enlarges and from ten to twenty little projections are seen 
on it by using a hand mirror. The breast has a firmer and more 
knotty feeling and its veins under the skin are larger and bluer. 
After the third month a clear fluid can usually be squeezed from 
the breast and later on a little milky fluid. These breast symptoms 
are more reliable in women who have never had children, as, in 
those who have, the breast changes noted are already present to a 
certain extent. 

Pregnant women are susceptible to various other ailments, as 
nervous changes, irritability, piles, varicose veins, salivation, tooth- 
ache, sour stomach, heartburn, constipation, itching, cramps, breath- 
lessness, backache, and the "whites*" 



SIGNS OF PKEGNANCY 211 

Women sometimes imagine that they are pregnant, having all the 
signs mentioned — absence of unwell periods, morning sickness, breast 
changes, enlargement of the abdomen, and finally labor pains — only 
to give birth in the end (as Dr. Wrench expresses it) to "bitter 
disappointment." This condition (spurious pregnancy) is due to 
continual distention of the bowels with gas, or to accumulation of 
fat, or the presence of a tumor combined with a peculiar nervous 
condition (as hysteria), and may occur in young married women or 
in women at the "change of life." 

There are certain distinctions between pregnancy and such rare 
conditions. In pregnancy the enlargement begins low down in the 
abdomen about the end of the sixteenth week and increases steadily, 
and is hard and not soft, as with fat. 

The navel flattens out or actually bulges, in the latter months of 
pregnancy, but dips in as usual in the fat. In the last few weeks of 
pregnancy the womb drops down so that a flattened space is left in 
the abdomen below the breast bone. If a doctor can hear the heart of 
the child beating (after the end of the fifth month) or feel its move- 
ments in the abdomen of the woman (after four and one-half months), 
the diagnosis of pregnancy is absolute. 

MISCARRIAGE * 

The most common cause of flowing during pregnancy is threat- 
ened abortion. In such a case the patient should at once go to bed, 
save all the discharge, clots, etc., which come aw T ay, and send for a 
doctor without delay. In case a physician cannot be reached the 
patient may also take a tablespoonful of paregoric, or ten drops of 
laudanum, in water, but neither of these should be repeated. 2 

Miscarriage is most frequent during the first three months, and 
again after the twentieth week, so that within these times the preg- 
nant woman should be particularly careful. Miscarriage within the 
first ten weeks is often a simple and painless matter, but all mis- 

1 Miscarriage and abortion are used synonymously here. More precisely 
abortion means expulsion of the child during the first three months, and mis- 
carriage expulsion from the third to seventh month, and premature labor after 
that time. 

2 Both forms of opium are powerful preparations, sold only on a doctor's 
prescription. 



212 DISEASES OF WOMEN— CHANGE OF LIFE 

carriages must be carefully treated because danger threatens — if 
there is neglect — through bleeding and blood poisoning. The first 
danger results from retained afterbirth and the latter from uncleanly 
attendance. 

Miscarriages should on the whole be taken as seriously as child- 
birth, because the danger is about the same in each. There is one 
miscarriage to every five childbirths, and almost every other married 
woman has a miscarriage at some time. 

Causes. — Miscarriage is caused by many fevers and chronic dis- 
eases, among which syphilis is by far the most common cause. Other 
causes include displacements of the Avomb. hot douches, hot baths, 
nervous shocks, riding in jolting conveyances, riding the bicycle or 
horse, pedaling a sewing machine, long walks and dancing, the use 
of alcohol or strong cathartics, hot or cold baths, frequent sexual inter- 
course and nursing a baby during pregnancy. All these causes should 
therefore be avoided by pregnant women if possible. 

When bleeding continues, following an abortion, it is usually a 
sign that a part of the afterbirth has remained in the womb. This 
should be immediately removed by a physician to avoid the dangers 
of possible blood poisoning. After the twentieth week it is common 
for the child and afterbirth to come away entire, but in the first 
three months this frequently does not occur. 

DEATH OF CHILD IN THE WOMB 

This is a comparatively rare occurrence. The mother has a cold 
feeling in the lower part of the abdomen and notices that neither 
the belly nor breasts continue to enlarge. There may also be a 
brown discharge from the private parts. The danger to the mother 
is not great if the case is managed by a competent doctor. 



CHANGE OF LIFE OR MENOPAUSE 

Change of life marks the end of active sexual life in woman, 
although the pleasure resulting from sexual intercourse may remain 
for several years after this period. 



CHANGE OF LIFE OR MENOPAUSE 213 

Change of life begins with irregularity in the time and amount of 
flowing, and after the flowing has permanently ceased, the general 
symptoms to be described may occur. In the healthy woman the 
discomfort of this period is comparatively slight; the intervals be- 
tween the periods are irregular and increase, while the flow may be 
scantier or much greater. 

The change requires from many months to five years for its com- 
pletion, and the average age at which it begins varies from forty-five 
to fifty, and more rarely from forty to fifty-two years. Flowing later 
than the latter period is abnormal. Change of life more often occurs 
early in women who have not borne children, or have suffered from 
grief, anxiety, disease, and exhausting pregnancies ; also in the fat ; 
while the menopause is more apt to be deferred in healthy and happily 
married women who have borne children. The unwell periods occa- 
sionally cease early, and after a considerable time may begin again, 
but such an unusual condition should receive medical attention. 
Menstruation is so irregular and different than usual, during the 
change of life, that it is wiser to consult a doctor because it not infre- 
quently happens that an unusual flow or discharge is attributed to 
the time of life when it may indicate a serious condition which 
cannot receive too early attention. 

The chief general disturbances are those affecting the circulation 
and nervous system. These include the rush of blood to the face 
and head, a hot flushes," headache, nosebleed, shortness of breath on 
exertion, floating spots before the eyes, giddiness, throbbing of the 
heart, faintness, and noises in the ears. Then there is irritability 
of temper, unreasonable dread, as of cancer of the womb or breast, 
and emotional excitement. Free perspiration, numbness, tender spots, 
and neuralgia may be present. The character may change so that 
the patient is indecisive, moody, and there is some failure of judgment 
and memory. There may be sleepiness, or sleep may be poor, and 
sometimes the sexual desires are unpleasantly strong. Digestive 
disorders, with flatulence, constipation, or diarrhea, are not unusual. 
If there has been ill health from disease of the tubes, ovaries, etc., it 
often ceases and patients become robust. After the flow has finally 
disappeared there may be a mucous discharge at intervals. 



214 DISEASES OF WOMEN— CHANGE OF LIFE 

The reappearance of blood should be a sign to the patient to 
consult a doctor. Ordinarily women soon recover their health and 
often gain in flesh, but in some cases they become thinner. Profuse 
and continuous flowing or serious mental disturbance during the 
change of life should always demand medical attendance and not be 
neglected because due to supposedly natural causes. 

Treatment. — During the menopause women should be protected 
from worry, responsibility, and overfatigue. A daily warm bath 
(105° F.) is useful in overcoming the flushing of the skin. The 
woman should stay submerged in it for fifteen minutes, adding as 
much water as necessary to keep up the temperature. Massage is 
particularly good for irritable skin and digestion. Tea, coffee and 
alcohol are inadvisable and the food should be digestible, with a 
minimum of meat. The patient should retire so as to get at least an 
hour of sleep before midnight and take her breakfast in bed. The 
bowels are kept free by means of a diet of vegetables and stewed 
fruits, honey, etc. (see Constipation), and by the use of a little 
Carlsbad salts in a glass of water on arising. 

General nervousness is benefited by ten grains of strontium bromid 
in one teaspoonful of tincture of valerian three times daily in half 
a tumbler of water after meals ; or a five-grain asafetida pill taken 
after each meal and at bedtime may be used instead. It is, however, 
unwise, to take either stimulants or sedatives continually. 



CHAPTER XII 
PREGNANCY 

Hygiene of pregnancy. Treatment of ills accompanying pregnancy. List 
of articles for childbirth. Emergency care of childbirth. Aftercare of 
mother. 

HYGIENE OF PREGNANCY 

The symptoms and signs of pregnancy are discussed in the pre- 
ceding chapter. The duration of pregnancy from the first day of 
the last menstruation is two hundred and eighty days. A simple 
method of reckoning is to count back three months from the first 
day of the last menstruation and add seven days, in order to find 
the date of expected birth of the child. This is correct for seven 
months in the year, but from four to six days should be added 
when conception occurs in the other months. 

The adding of two hundred and eighty days to the date of the 
first day of the last menstruation is the most accurate method of 
ascertaining the date of expected labor. When the date of probable 
conception is known then labor may be expected in two hundred 
and seventy-one days from that time. It is well to acquaint the 
doctor, who is to have charge of the case, as soon as the fact of 
pregnancy is probable. He will desire to examine the urine weekly 
during pregnancy, and also to examine the mother with a first child 
to ascertain whether the baby may be born without hindrance, and 
to determine the position of the child. 

Exercise for the pregnant woman is essential to strengthen the 
muscles on which an easy labor depends, but stretching, lifting, 
jarring, jumping, the use of the sewing machine, bicycling, riding, 
motoring (except upon smooth pavements), and dancing, should be 

215 



216 PREGNANCY 

avoided. The patient should reduce the amount of exercise to which 
she has been accustomed. 

A large amount of food is requisite, but the separate meals 
should not be large, especially as pregnancy advances. To avoid 
this there should be light lunches taken between the regular meals 
and at bedtime. One of the chief dangers of pregnancy consists in 
the large amount of waste matter resulting from the activity of 
the vital processes going on in the body of the mother and child, 
and this is best eliminated by the use of daily warm baths (not 
hot), the drinking of six or eight glasses of cool (not iced) water 
during the day, preferably half an hour before meals and at bed- 
time. Also for the same purpose the bowels must be kept open each 
day. If the diet recommended, under Constipation, will not suffice, 
then some mild cathartic may be taken, as a teaspoonful of com- 
pound licorice powder, or one or two compound laxative pills at 
night, or a Seidlitz powder or a teaspoonful or more of sodium 
phosphate in a glass of cold water on arising. 

Since the clothing should be loose, corsets are inadvisable after 
the first few months, and a linen waist, sold for this purpose, may 
be worn, to which the lower garments and stockings are fastened. 
Circular garters favor enlargement of the veins in the legs. An 
abdominal support affords great relief in the later months of preg- 
nancy, such as the Storm binder. 

The teeth are prone to decay during pregnancy because the lime 
salts are used up in the growth of the child, but especially because 
of frequent acid eructations from the stomach into the mouth which 
destroy the teeth. It is wise to brush the teeth three times daily 
with milk of magnesia and to consult the dentist at frequent inter- 
vals during this time. 

Most women have a good appetite and gain in weight and good 
looks during pregnancy, but if they fail in health and grow thin, then 
iron and lime are needed as well as frequent examinations of the 
urine. One Blaud's five-grain pill of iron, and two teaspoonfuls 
of the syrup of calcium lactophosphate should be taken in water, 
three times daily after meals. 

Pregnant women require at least eight hours' sleep and plenty 



TREATMENT OF ILLS ACCOMPANYING PREGNANCY 217 

of fresh air. As much as three pints of urine should be passed daily, 
and if this does not occur, when the quantity of water advised is 
taken, then a physician should be consulted. 

Milk or other fluids, as cocoa, may be substituted to some extent 
for water. There should be great moderation in tea and coffee — 
not more than one cup of either daily; and alcohol in any form 
is usually harmful. Fried food, pastries and sweets must be avoided, 
and meat should be eaten in moderation but once daily. 

The chief danger in pregnancy is from a kind of poisoning 
which, in its worst form, causes convulsions late in pregnancy. 
To avoid this the drinking of water, the exercising, and elimination 
of waste matters by increased urinary secretion and daily movement 
of the bowels, together with activity of the skin, produced by warm 
baths, are all important. The avoidance of much meat is also 
important since the waste matters from meat are eliminated by the 
kidneys, already overworked. 

Sexual intercourse is allowable, providing it is moderate and 
the times of its occurrence do not coincide with the dates of menstru- 
ation — were they present. It should be avoided by the pregnant 
woman during the last month of pregnancy, owing to the size of the 
abdomen, and in case of former miscarriages the danger of another 
is increased by sexual intercourse. Sexual intercourse is inadvisable 
for six weeks after childbirth. 



TREATMENT OF ILLS ACCOMPANYING PREGNANCY 

A discharge (leukorrhea) from the vagina is quite common in 
pregnancy and this may cause irritation and itching of the external 
parts. An injection consisting of a pint of tepid water containing 
a teaspoonful of boric acid may be taken daily for this trouble, and 
the external parts washed frequently with the same. To relieve the 
itching, cloths wet in a strong solution of baking soda and water 
may be laid on the itching parts, and this followed by the applica- 
tion of carbolized vaselin. 

Nausea and vomiting are among the most common troubles of 



218 PREGNANCY 

the first months of pregnancy. The "morning sickness" is best 
avoided by the patient lying in bed until after breakfast, or for half 
an hour after a cup of hot milk or cocoa have been taken. Severe 
vomiting will require the services of a physician. Heartburn is 
frequent in pregnant women and is relieved by taking a teaspoonful 
of magnesia (Husband's) or baking soda in a glass of water. 

Neuralgias often occur, particularly about the face; and also 
pain in the upper part of the back of the thigh, resembling sciatica, 
more troublesome on walking. A dentist should examine the teeth 
to see that the neuralgia of the face is not caused by a decayed tooth. 
If not so caused, then the rubbing on the painful parts of analgesic 
ointment (sold in collapsible tubes), or the application of a hot 
water bag may relieve the trouble. The pain in the thigh is due 
usually either to pressure of the child's head on the nerves in the 
back of the bony cavity (pelvis) of the mother, or to loosening of 
the joints at the base of the spine. If the patient assume a position 
on the bed, face downward and resting on the chest and knees until 
beginning fatigue, two or three times daily, the position of the child 
may change and the pressure on the nerves of the mother be relieved. 
This should more properly be done with the consent of the physician 
in charge. Sometimes the wearing of an abdominal support, as 
advised above, will give relief when there is looseness in the joints 
at the base of the spine. 

Varicose or enlarged veins of the legs and thighs are natural 
consequences of pregnancy. Relief from the discomfort caused by 
them may be obtained by the use of the elastic stocking fitted by 
the makers of surgical appliances; or a flannel bandage about eight 
yards long may be made at home by sewing together strips four 
inches wide, and cut on the bias, into a strip. This should be 
wound into a roll and applied before rising in the morning. It 
should be started at the toes and wound from thence about the leg 
up to the top of the thigh and fastened there. After retiring at 
night the bandage is to be removed and rolled. 

Excessive secretion of saliva is common in pregnant women and 
cannot readily be prevented. Frequent passage of urine is also 
usual, occurring more often during the first three or four months 



TREATMENT OF ILLS ACCOMPANYING PREGNANCY 219 

from pressure of the child upon the bladder, and during the last 
two months from alteration in the shape of the bladder. This cannot 
be avoided, but if the urine becomes thick and cloudy the condition 
should at once be referred to the doctor. Cramps at night are 
annoying, attacking the legs. They may perhaps be averted by 
rubbing of the legs from below upwards before retiring. 

Sleeplessness, more often during the later months, is occasionally 
vexatious. The use of a glass of warm milk or a glass of beer, 
before going to bed, or when wakeful at night, may be helpful. 
This means failing, sodium bromid (thirty grains) dissolved in a 
glass of water, and one-third of this taken at two, six and nine 
p. m. may relieve the trouble. More powerful remedies for the 
production of sleep should only be taken on medical advice. 

During the last month of pregnancy the nipples should be bathed 
in alcohol, and glycerite of tannin should be then rubbed on them 
daily to harden the nipple. If the nipple is depressed and shrunken 
it may be pulled outward, but much manipulation of the breast is 
inadvisable as it stimulates the womb. 

Every pregnant woman should have impressed upon her the fact 
that the appearance of certain symptoms should warn her to at 
once consult her doctor. These include the following: flowing of 
blood from the front passage or vagina, severe headache or pain in 
the stomach, dizziness and imperfect eyesight, nausea and vomiting 
during the later months, and swelling of the face and hands. These 
are, or may be, danger signals not to be neglected. 

The mental state of the pregnant woman is often subject to 
change, and is one of the symptoms of her condition. Her character 
may be altered, and she may become irritable, suspicious, and difficult 
to live with. Only cheerful influences should surround her and the 
cares incident to business should be kept from her. She should 
also avoid any extensive social activity. Any marked unnatural 
mental state in the pregnant is of course unusual and a doctor should 
at once be consulted. 

The shape of the child in the womb is not in any way influenced 
by unpleasant sights, frights, or impressions which its mother may 
have experienced during pregnancy ; neither is its character changed 



220 PREGNANCY 

one iota by any specially delightful or uplifting influences to which 
the mother may subject herself, with this end in view, during preg- 
nancy. Furthermore, there are no known means by which a doctor 
or any one may regulate, or even foretell the sex of the forthcoming 
offspring, notwithstanding popular teachings to the contrary. 

The former idea that a pregnant woman should be left to shift 
for herself is fortunately passing. She should be under constant 
supervision of the doctor during the whole period of pregnancy 
in order that he may anticipate any trouble which may at times 
come on with great rapidity. It is the author's custom to see his 
pregnant patients weekly and secure a specimen of urine at those 
times. Most patients are able to come to his office. 

LIST OF ARTICLES FOR CHILDBIRTH 

One dozen clean sheets 
One dozen clean towels 
Four strips of unbleached cotton, one and one-fourth by one-half yard, 

for binders 
One strip of flannel, eighteen inches long by eight inches wide, for 

binder for the baby 
One rubber sheet, or piece of enamel cloth long enough to reach across 

the bed, and one yard wide 
One douche pan of the rectangular type, with a square shelf to put 

beneath the patient 
One fountain syringe 
One-half pound of absorbent cotton 
Four dozen pads for absorbing discharge 
Linen bobbin one-sixteenth inch wide, or very narrow tape one foot 

long for tying the navel cord 
One pair of scissors 
One bottle containing seven and one-half grain corrosive sublimate 

tablets 
One-quarter pound of boric acid 

Four cheap nail brushes wrapped in gauze, and boiled ten minutes 
One ounce of boric acid dissolved in one quart of water previously boiled 

and kept in a tight Mason jar 
Four ounces of brandy or whisky 
One-half ounce of fresh Squibb 's fluid extract of ergot 



LIST OF ARTICLES FOR CHILDBIRTH 221 

Two tubes of vaselin 

One cake of Castile soap 

Three agateware basins 

One slop jar 

One pan under bed for afterbirth 

Oilcloth or newspapers to spread on the floor under the bed to protect the 

carpet 
One gallon of water which has been boiled and kept in a clean pitcher 

covered with a clean towel and a gallon of hot water 
Baby's clothing and blanket to wrap the infant in 

Note. — The pads which are worn after confinement are made of cotton bat- 
ting wrapped in cheesecloth and are sterilized by being put into a slow oven and 
baked until they are a light russet brown. The pads should be all wrapped 
together in a piece of cotton and the package should not be opened until the 
pads are to be used, the rest of the pads being kept covered from dust. A sample 
pad covered with cotton cloth is put into the oven and, by observing this, one 
can decide when to take the large package out. The pads of cotton batting 
should be three inches thick, four inches wide, eight inches long, and wrapped 
in cheesecloth strips two feet long, each end of which is pinned to the binder 
about the patient. 

BABY'S CLOTHES 

Four to six dozen diapers 
Four to six pairs knit woolen socks 
Three to four woolen shirts 
Four flannel night shirts 
Four flannel day skirts 
Four to six white day skirts 
Six to ten slips 
Six to ten dresses 
Four or five flannel bands 
Soft pillow, fourteen by eighteen inches 
Soft pillow covers 
Knit wrapping blankets 

Sacques, wrappers, bibs, caps, blankets, veils, etc. 
Note. — All skirts to be made with waists instead of bands. 

BABY'S BASKET 

Large and small safety pins 

Talcum powder, box, and puff 

Fine, soft sponge 

Soft brush for hair 

Castile soap 

Cold cream 

Alcohol for rubbing child 



222 PREGNANCY 

BABY'S BASKET (Continued) 
Blunt scissors for nails 
Old linen for cleaning month 
Soft towels for bath 
Bath blanket 

Wooden forms for drying socks 
Wooden horse for drying diapers (Hirst) 



CARE OP THE MOTHER DURING CHILDBIRTH IN THE AB- 
SENCE OF A DOCTOR 

The duration of labor averages about eighteen hours in the case 
of the first child, and about twelve hours in women who have already 
borne children. The time varies greatly in individual cases. 

Moderate pain in the lower part of the back is usually the first 
symptom of labor, followed by severe pains, with intervals of rest, 
in the lower part of the belly. With the hand over the lower part 
of the belly the womb may be felt to harden with each pain. Some 
time before the child is born "the waters break," that is the mem- 
branous sac inclosing the child ruptures and the water escapes in 
which the infant has been floating. Occasionally the child is born in 
the sac (with a caul), so that it may be necessary to rupture it and 
remove the baby. 

A full bath should be given the patient at the first intimation 
of labor, and the inside of the thighs, the lower part of the belly, 
and the- external parts about the entrance to the front passage (va- 
gina), as well as about the back passage, should be scrubbed with 
soap and water some ten minutes. The hair about this region 
should also be clipped or shaved. The giving of a soapsuds enema 
to empty the bowels is desirable also to make more room for the 
birth of the child. The bed on which the patient is to be delivered 
must be supplied with clean sheets and pillow cases. The bed should 
then be protected by laying a rubber sheet, enamel cloth or com- 
forter, folded two feet wide, across the clean sheet in the middle 
of the bed under that section of the bed which will be occupied by 
the buttocks of the patient. 



CARE OF THE MOTHER DURING CHILDBIRTH 22:} 

Then another clean sheet will cover this. After labor these will 
be removed and a pad of cotton batting and cheesecloth will be 
kept under the patient. 

The patient may be encouraged to walk about from the time 
of the first pain until the membranes break or, when this happens 
early, until the child's head causes the parts to bulge about the 
outlet. The mother should not go to the closet during labor, as 
infants have been expelled during such times. Labor may be has- 
tened in the later stages by the patient lying in bed, holding her 
breath, bracing her feet against the footboard of the bed, and pulling 
on a sheet attached to it during the pains. She should strain just 
as if she were trying to have a movement of the bowels. When the 
head of the child begins to show the patient should cease all strain- 
ing. 

The hands of the attendant should be absolutely clean. After 
cleaning her finger nails, she should scrub her hands and forearms 
for fully ten minutes with soap, warm water, and a scrubbing brush, 
and then rinse them in water which has been boiled. 

When, by frequent inspection, it is seen that the child's head 
is so low down that the parts between the front and back passage 
bulge, and the head becomes visible during a pain, the patient is 
to be placed in bed upon her left side, with her thighs drawn up 
against her body and a pillow between her knees, and pressure 
should be made by the attendant's hand against the bulging parts 
to prevent the expulsion of the baby until the parts are properly 
stretched — so that they will not be torn during birth of the infant. 

When the head is born see that the cord is not wound about 
the neck; untwist it if it is, and support the head. If the rest 
of the body is not soon expelled, press and knead the lower part 
of the mother's belly, forcing it out. If this does not succeed after 
ten minutes, extract the child by gentle force, pulling steadily on 
the child's head and freeing one arm at a time. As soon as the 
child is born an assistant should sit by the right side of the mother — 
and, pressing on the outside of the lower part of her belly, should 
grasp the womb between the thumb and fingers of the right hand 
and hold it firmly, kneading it if it gets soft, until the afterbirth 



224 PREGNANCY 

is expelled. Pressure must be kept up on the womb for half an 
hour after the afterbirth has come away as well. 

Nothing in the whole care of the woman in labor is more im- 
portant than the pressure on the womb to stop dangerous bleeding 
from this organ. It is absolutely indispensable, even if the pressure 
gives discomfort to the patient. 

As soon as the child is born it is most vital that he shall breathe 
satisfactorily. If he does not breathe the cord should be immediately 
cut, but otherwise it is wise to wait three minutes in order that 
the infant may receive a few ounces more blood from the mother. 

The baby may lie supported on the abdomen of the mother while 
the cord is cut. The cord is tied at two places; at a point two 
inches and at a point four inches from its attachment to the infant's 
body. 

A clean, narrow piece of tape, or soft white string (which has 
been boiled five minutes), is wound about the cord tightly and tied 
securely at each of the above points so as to stop the bleeding after 
the cord is cut. 

The cord is then severed midway between these two points with 
a clean pair of scissors which have been boiled five minutes. If 
any bleeding occurs from either cut end of the cord it should be 
stopped by tying another piece of tape about it. 

Now if the baby does not cry or breathe freely, spank it gently 
and slap it on the soles of the feet. If this does not bring about 
the desired result try immersion in water. Into one of the basins 
provided pour water as hot as the hand can comfortably bear; into 
the other basin pour cold water. Grasping the infant by the feet 
and hands, immerse him, all but the head, first in one basin and 
then in the other, every few seconds. If after he has been thus 
dipped six times in each basin and he still fails to breathe, lay him 
on his back on the table, and raise his arms up above his head as far 
as possible, and after three seconds carry them down again along- 
side of his chest, making pressure on his chest with them just as in 
resuscitating a drowned person. During this process the baby should 
lie on a blanket in a very warm room. 

Before the artificial breathing is done it is well to hold the baby 



CAEE OF THE MOTHER DURING CHILDBIRTH 225 

upside down by the feet for an instant, while the little finger (of 
the nurse) is introduced back into the mouth of the baby to clear 
away mucus and secretions interfering with breathing. 

If this method fails then wrap the baby in a blanket and try 
"mouth to mouth inflation." This is done as follows : cleanse the 
mouth with a moistened clean towel. Put your little finger in the 
baby's mouth at one side to hold down his tongue. Place your 
mouth closely over his and blow into his lungs with your own breath, 
steadily and powerfully, so as to inflate the baby's chest. Count 
six slowly between the inflations while compressing the sides of the 
baby's chest after each inflation. In other words, one alternately 
fills the baby's chest with air and then forces it out by stopping 
the inflation and pressing in the lower part of the infant's chest. 
A baby who has thus been brought to life should be examined every 
ten minutes during the first twelve hours of his life, and if breathing 
fails again, the same process of inflation should be repeated. It 
will be seen that two attendants are desirable in childbirth, one to 
care for the mother and the other to look after the newborn baby. 
This of course may be impossible and in most cases, after the cord 
has been tied and cut, the baby is breathing normally and can be 
wrapped in a blanket and placed in his basket in a warm place out 
of the way, where he cannot be sat upon or harmed. 

When two attendants are available one has, meanwhile, been 
sitting at the mother's side holding down and occasionally kneading 
the womb, and has also given the mother a teaspoonful of fluid- 
extract of ergot in one-third of a cup of water as soon as the child 
was born. This should be prepared beforehand so that it may be 
given the moment the child is born to prevent bleeding from the 
mother's womb, the danger most to be feared. The compression and 
kneading of the womb through the abdomen has a twofold purpose 
■ — to prevent bleeding and hasten the expulsion of the afterbirth. 
If the womb contracts rapidly and all bleeding ceases, the mother 
may fall asleep for a few minutes while the nurse still holds the 
womb. If over half an hour elapses after the birth of the child 
and the afterbirth has not come away, its delivery may be secured 
by pressing with force upon the lower part of the belly and kneading 



226 PREGNANCY 

the womb forcibly through the abdominal wall and so squeezing 
the afterbirth out. 

But do not pull with any force upon the cord, which is a danger- 
ous proceeding, as it may break. The afterbirth usually comes 
away in about fifteen minutes after the birth of the child, if the 
uterus is firmly compressed during this time. The afterbirth is 
caught in a basin together with the gush of blood which often follows 
it. When the afterbirth appears at the outlet it should be grasped 
by both hands and gently withdrawn, being careful not to break 
and leave behind the strip of membrane attached to it. This is 
best managed by moving the afterbirth up and down, with a rocking 
motion, while pulling it gently away from the mother. 



CARE OF THE MOTHER AFTER CHILDBIRTH 

After the child and afterbirth have both been delivered the 
attendant must still sit by the side of the patient grasping her womb 
firmly through the abdominal wall for about one-half hour. The 
patient lies on her back during this time and should be kept on her 
back most of the time for the next week. After half an hour has 
elapsed, and the womb is felt to be hard and well contracted, the 
attendant should wash off the external parts about the vagina with 
warm boiled water or corrosive sublimate solution (one tablet to the 
quart of water), using one of the prepared pads as a sponge. 

The binder is now tightly applied about the body, from below 
the breasts to a point below the hips, and snugly fastened with 
safety pins. It is well to lay a towel, folded into a square as large 
as the hand, under the binder and over the womb so that pressure 
will be made on the womb to replace that of the hand. A baked 
pad is now placed over the entrance to the front passage, and held 
in place by attaching each end to the binder by safety pins. The 
body clothing and bed linen must next be changed, with as little 
disturbance of the patient as possible. A clean sheet, folded three 
times (draw sheet), is laid across the bed over the under sheet and 
under the middle of the patient, and tucked in at its ends, to protect 



CARE OF THE MOTHER AFTER CHILDBIRTH 227 

the mattress. In addition, it is wise to keep a pad of cotton batting 
and cheesecloth, under the patient's buttocks for the same purpose. 

After this is completed the room should be darkened and the 
patient covered warmly, as a chill often occurs after childbirth, and 
she should be kept absolutely quiet, receive no visitors, and have 
three or four hours of complete rest. If there should be at any 
time much bleeding from the womb, firm pressure must be immedi- 
ately made on the womb over the lower part of the belly, and kept 
up for half an hour, despite the discomfort to the patient and her 
remonstrances. Also give one-half teaspoonful of fluidextract of 
ergot hourly till four doses have been taken. 

After four to eight hours of rest on her back the patient may 
lie on her side for a time, if she so desires, and the baby may be 
put to the breasts, first to one, then the other, at the same feeding, 
at four-hour intervals until the milk comes on the third day, and 
after this time the baby should nurse every two hours by day, with 
an interval of four or five hours at night. The first secretion of the 
breast before the real milk comes is laxative to the baby. No other 
food should be given the baby. 

The pads on the mother should be changed as often as they 
become soaked with discharge and should not remain long enough 
to acquire any odor. Before applying a clean pad, and after urina- 
tion and bowel movements, a pitcher of warm water containing 
corrosive sublimate (one tablet to two quarts) should be poured 
slowly over the external parts to wash off the blood and discharges 
while the patient is lying on a bedpan. 

The urine should be passed once in eight hours. Considerable 
trouble is often experienced to get the patient to pass urine within 
this time after labor. One should not try to make the patient 
pass urine until twelve or even twenty-four hours after labor, if 
the act is difficult. At the end of that time various methods may 
aid the act. Thus allowing the sound of running water to reach 
the patient, placing hot cloths over the lower abdomen, permitting 
warm corrosive solution (as above) to flow over the external parts, 
and by giving an injection of one quart of warm water into the 
bowel, the urine may flow with the escape of the injection from the 



228 PREGNANCY 

rectum. If all these methods fail, and a physician is not available, 
the patient may be aided to sit upon a vessel, but this is to be 
avoided if in any way possible. Finally, if the patient is still un- 
able to pass urine, the attendant must use a catheter and draw off 
the urine. 

Pains in the womb after labor (after pains) are more common in 
women who have borne children. They mean that some clots remain 
in the womb and should be expelled to avoid their putrefaction. 
Kneading the belly over the womb and the use of hot poultices over 
the lower part of the belly are remedial. 

The sickroom should be well ventilated and the patient should 
be sponged with warm water from head to foot once daily. The 
diet for the first two days consists of milk, broths, weak tea, and 
cocoa; for the next two days cereals, milk toast, soft eggs, soups, 
wine jelly, and one cup of tea or coffee. The meals should be served 
every two hours the first four days. 

After the fourth day the diet should consist of simple food, 
as mashed or baked potatoes, toast or stale bread, soft eggs (boiled, 
poached or scrambled) ; chops, steak, roast lamb or chicken once 
daily; cereals, stewed fruits, and jellies. Then a gradual return to 
ordinary diet should follow. 

In addition to the three chief meals a glass of milk should be 
given three times daily, between meals and at bedtime. Raw vege- 
tables or fruit, except grapefruit, oranges or grapes, are undesirable. 

The bowels are to be moved on the morniner of the third dav 
after labor by a half bottle of magnesium citrate, or a tablespoonful 
of Epsom salts in a whole glass of cool water before eating. If 
a movement does not occur four hours after the cathartic, an injec- 
tion of soapsuds should be given. The bowels should be moved daily 
thereafter by laxatives as lapactic pills, one or two at night, or aro- 
matic fluidextract of cascara sagrada, one-half to one teaspoonful at 
night. If the cathartic is not successful an enema of soapsuds 
should be given with the patient on a bedpan. 

Giving a douche or injection into the front passage (vagina) 
is not advisable unless the discharge has a foul odor. Then an 
injection of two quarts of wami water, in which two corrosive 



CARE OF THE MOTHER AFTER CHILDBIRTH 229 

sublimate tablets have been dissolved, may be given with the patient 
on her back on a bedpan. 

The breasts are apt to cause trouble on the third day or so, 
when the milk secretion is beginning. To avoid this, as the breasts 
become tense, full, and painful, they should be covered with a 
layer of cotton batting, and drawn together by a tight bandage 
eight inches wide, encircling the chest, and fastened in front by 
safety pins. The bandage is held up from slipping off the breast by 
straps of folded cotton cloth, two inches wide, passing over each 
shoulder and attached to the upper edge of the band about the 
body, before and behind. A piece of absorbent cotton should be 
laid between the breasts, and some talcum powder dusted in the 
crease, to prevent chafing and soreness. This should be done before 
fastening the bandage. The pressure of the bandage on the breasts 
prevents them from filling up and becoming painful, so it is essential 
that it be tight. An opening should be cut in the bandage over each 
nipple that the baby may nurse. 

The nipples should be washed off with a solution of boric acid 
(as much as warm water will dissolve) before and after each nursing 
and then the nipples should be anointed with vaselin. A little ab- 
sorbent cotton wound about a toothpick makes a good swab for 
washing the nipples. 

If there are any lumps in the breast the bandage should be 
rubbed with the oiled hand, beginning gently and stroking the 
breast from the outside toward the nipple, when the milk will begin 
to flow, and after rubbing for a time the tenderness, great at first, 
will disappear with the lumps. Keeping warm, hot pads of cheese- 
cloth over the breasts, wet with strong boric acid solution, will also 
take the soreness out of the breasts. Constant pressure by a bandage 
in the first place is the best means of preventing soreness in the 
breasts and a few days after the milk has appeared this will usually 
pass away. 

When the baby cannot nurse, because the milk disagrees with 
him or for any other reason, there will be more trouble with the 
breasts for a few days after the milk comes into them. The same 
treatment should be pursued, but a breast pump should also be used 



230 PREGNANCY 

two or three times a day, and the breasts kept tightly bandaged 
in the interim. Giving the patient two tablespoonfuls of Epsom 
salts the morning after the third day tends to reduce temporarily 
any oversecretion of milk. 

If the breasts are actually inflamed and the skin reddened, or 
if there is throbbing pain in the breast and pain on moving the 
arm on that side, and fever, then nursing must be stopped in both 
breasts and an icebag or hot poultices should be applied to the 
sore breast and a surgeon summoned as soon as possible. Abscess 
or "broken breast" will be avoided in part by the measures already 
described, but another preventive means is the washing of the child's 
mouth and mother's nipples before and after nursing, with boric acid 
as described above. 

Besides this the breasts should be kept absolutely clean with 
soap and water. Cracks in the nipples are the chief source of late 
abscess of the breast. If one occurs it should be touched three times 
a day with compound tincture of benzoin on a clean toothpick and 
use a nipple shield. The advice of a doctor is desirable. Both 
nipple shields and breast pumps must be washed and boiled five 
minutes after using, and be kept in boric acid solution when not 
in use. 

N~o visitors, except the patient's mother and husband, are ad- 
visable during the time she is in bed. 

The patient may turn freely in bed after the first week, and 
then it is advisable for her to lie for fen minutes night and morning 
with her back uppermost and resting on her knees, chest, and side 
of her face. 

This position throws the womb forward and prevents it becom- 
ing displaced backward. If the patient will take deep breaths 
while in this position the effect is increased. A physician should 
examine every woman after childbirth at the end of two weeks 
and six weeks, to determine the damage done and the success of 
nature's repair. 

The chief danger of childbirth — childbed fever — may be abso- 
lutely avoided by perfect cleanliness in regard to the patient, as 
has been described, and this applies all through the convalescence. 



CARE OF THE MOTHER AFTER CHILDBIRTH 231 

The nurse should always wash her hands thoroughly hefore touch- 
ing the patient, while all clothing coming in contact with the patient 
should be scrupulously clean. 

The occurrence of fever during the first week after labor is the 
first sign suggestive of blood poisoning and demands the imme- 
diate attention of a doctor. A scanty and foul-smelling discharge 
from the vagina is another bad sign. 

The temperature should always be taken twice daily for ten 
days after labor and a temperature of 100° F. or over is a danger 
signal. The patient should stay in bed two weeks, pass the third 
week between the bed and lounge, and be dressed and go about 
during the fourth week after labor. 



CHAPTER XIII 
CARE OF THE BABY AFTER BIRTH 

Immediate care after birth. Bathing. The skin. Clothing. Temperature. 
Ventilation and fresh air. Weight. Walking and talking. Bowel dis- 
charges. Teething. Xursing at the breast. Bad habits, including 
masturbation, sleeplessness, sucking, and bed- wetting. Preparing milk 
and other food for bottle feeding. Utensils used in bottle feeding. 

IMMEDIATE CARE AFTER BIRTH 

Immediately after tying the cord the baby's eyes should be cared 
for. It is always advisable to drop in each eye one drop of twenty- 
five per cent, solution of argyrol to prevent inflammation of the 
eyes and possible blindness. If argyrol is not at hand let boric 
acid solution (using as much boric acid as the water will dissolve) 
flow directly into the eyes from a cup, so that they are thoroughly 
cleansed. The use of argyrol solution with a medicine dropper is 
much to be preferred. 

The stump of the cord attached to the navel is best dressed with 
salicylated cotton, or absorbent cotton, wet with alcohol, wrapped 
about it. The 'baby should be anointed from head to foot with warm 
sweet oil or vaselin, and placed in a warm spot, but not bathed for 
some hours. Prom time to time the baby must be watched to see 
that the navel cord does not bleed, and if it does, another piece of 
narrow tape or cotton string, previously boiled, should be tied tightly 
about the stump. 

After a few hours the cheesy matter may be washed off the 
infant's body with warm water and Castile soap, the baby being 
held on the nurse's lap. 

232 



THE SKIN 233 

At the end of a week the baby may be bathed in a bathtub in 
water at 90° F., as shown by a bath thermometer. Until that time 
daily sponging may be done with water at 100° F., or, if the baby 
is feeble, he must be rubbed with warm olive oil instead. The 
dressing over the navel is kept in place by a loose, flannel binder. 
It is well to dust the navel cord with a mixture of salicylic acid 
(one part) and starch (five parts) each day. The cord should drop 
off the fifth day, and, if any raw spot remains, it should be cleaned 
by pouring on warm water, which has been previously boiled, and 
then dusted w T ith dry boric acid and covered with clean absorbent 
cotton. 

BATHING 

Bathing in the tub should be done in a warm room in the middle 
of the day and preferably in front of an open fire. First wash 
the head and face in water, without soap, and dry them. Then soap 
the body with Castile soap and place the baby in water in the tub 
at 90° F., and, while supporting his head and back, wash off the 
soap with a soft sponge. A cloth should be kept separate for use 
about the buttocks. 

The eyes should be bathed daily with boric acid solution (one- 
quarter teaspoonful to one pint of boiled water). The best way is 
to drop the solution in the eyes with a medicine dropper. Any 
soreness or discharge from the eyes should demand the immediate 
attention of a physician as it may be a very serious matter. 



THE SKIN 

Chafing is avoided by scrupulous cleanliness and changing of 
diapers as soon as soiled or wet; also by dusting in the folds of 
the skin a powder consisting of a mixture of starch (three parts) 
and boric acid (one part). Cold cream may also be used first on 
the chafed parts and the powder dusted on over this. If the skin 
is very delicate a bran bath may be used to advantage. This is 
made by tying one pint of bran in a bag of cheesecloth and placing 



234 CARE OF THE BABY AFTEE BIRTH 

it in the baby's bath for five minutes, and then squeezing it out 
thoroughly in the bath. The bag may be dried and used again. 

Drying should be done with a soft towel without rubbing. If 
there is a rash on the body it is wiser to omit the bath altogether 
until it is gone. 

CLOTHING 

A bellyband, four inches wide and long enough to encircle the 
body and overlap four inches, should be worn during the first six 
months. After this a knitted band may be used for two years. Most 
babies are dressed too warmly in the house and the house is over- 
heated. The thinnest gauze shirts are most suitable for summer, the 
next to the heaviest flannels in winter. Thick coats and leggings 
in winter, worn only when the infant goes out of doors, are better 
than heavy flannels worn all the time. 



TEMPERATURE 

The nursery should be kept at a temperature of 68° F. during 
the day, never above 70° F. at any time, and not below 65° F. at 
night, for the first three months. After the first year the tempera- 
ture may be as low as 40° to 50° F. at night. 

The windows may be open at night after the first three months, 
except in the coldest weather. If the child is born in hot weather 
of course the windows may be open at any time. It is well to air 
the room after the bathing time and at bed time. 

There should be no cooking, washing or drying clothes in the 
nursery, and there should be no unnecessary curtains, hangings or 
upholstery in the room, which should be large and sunshiny and 
heated preferably by an open grate. A gas stove for heating is 
unwholesome, except for temporary use for the bath. 



VENTILATION AND FRESH AIR 

The baby may go out of doors in summer when one week old; 
in winter on warm days when three months old, if kept out of 



WEIGHT 235 

the wind. A temperature below freezing, melting snow, or high 
winds, make outdoor airing inadvisable at this age. 

At one month, airing of the baby in the nursery, while dressed 
and in the crib, may be begun, at first for fifteen minutes, later 
it may be continued for an hour. This may be done in all except 
the most severe and inclement weather. To accomplish the airing, 
the windows of the nursery should be opened as wide as possible, 
doors being shut, and a screen being used if necessary on account 
of draught. 

When eight months old the baby may go out of doors in a car- 
riage, if the temperature is not below 20° F. The best hours are 
in the middle of the morning and afternoon. 

Sleeping while in the carriage in winter is allowable, if the wind 
and sun are not in the baby's face, and if the feet and body are 
well covered. The infant is as well off in a carriage as in the 
nurse's arms outdoors at any age. 

Colds may best be avoided by keeping the nursery cool, by not 
overdressing indoors, and by bathing the chest and back with water 
at 60° F., while the baby sits in warm water, at the close of the 
daily bath. 

WEIGHT 

The weight of a baby is the best guide in feeding and as to 
the general physical condition ; therefore the baby should be weighed 
regularly every week. During the first week there is commonly 
some loss of weight — the baby may even weigh one-half pound less 
at the end of the first week than at birth. From the end of the 
first week to the sixth month the average gain should be from four 
to eight ounces a week; from this time until the end of the first 
year, from two to four ounces each week. An average baby should 
weigh twelve pounds at three months ; fifteen pounds at six months ; 
seventeen pounds at nine months; twenty pounds at the end of the 
first year. 

The fontanel, or open spot in the top of the skull under the scalp, 
should close at eighteen months. The failure of the fontanel to 



236 CARE OF THE BABY AFTER BIRTH 

close at the end of the second year indicates some arrest in de- 
velopment which may be only due to previous malnutrition, or tc 
some more serious developmental irregularity. 



WALKING AND TALKING 

The baby holds up his head unassisted at the third or four month ; 
sits up unsupported at the end of the seventh month; and stands 
without assistance at about the end of the first year. 

At the end of fourteen or fifteen months a baby will usually 
begin to walk unassisted, although this is not to be encouraged. Baby 
usually begins to talk and say "mama" and "papa" at one year of 
age. If the child does not speak at all at the age of two there is 
a probability of deafness, or general arrest of development, which may 
prove the first sign of idiocy. There are of course many exceptions 
in the case of tardy development. 

BOWEL DISCHARGES 

During the first few days after birth the passages from the 
bowels are blackish and sticky, but as soon as the baby receives 
milk they become of a creamy consistence and of a bright yellow 
color without much odor. The occurrence of white lumps or curds 
in the bowel movements is usually a sign that the milk is too rich 
in fat. 

During the first weeks of life there are naturally from two to 
four movements daily. From two months to two years of age 
the movements normally number from one to three daily. After 
two years of age the passages become formed, and possess the char- 
acteristic odor of excrement. The appearance of blood in the dis- 
charges of the newborn is of serious significance. A greenish color 
of the movement often is characteristic of indigestion, but if the 
passage is of normal color when passed and later becomes green, the 
happening is of no significance. 

Medicines, like bismuth and iron, stain the bowel movements 



TEETHING 237 

black, as also does blood in the upper part of the digestive tract. 
Clay-colored passages generally mean some obstruction to the now 
of bile into the bowels. They accompany jaundice. 



TEETHING 

Babies are teething from the fifth month until two and one-half 
years of age. At two and one-half years the first set of twenty 
teeth, consisting of six front teeth and four back teeth on each 
jaw, should have been cut. The two central front teeth on the 
lower jaw appear first, between the fifth and ninth month of life. 
The four upper central front teeth are cut between the eighth and 
twelfth month. 

The remaining two lower front teeth and the four foremost back 
teeth (two on each jaw) come between the twelfth and eighteenth 
month. 

The eye teeth (between the front and back teeth on the 
upper jaw), and the stomach teeth (in the same position on the 
lower jaw) appear between the eighteenth and twenty-fourth 
month. The four hindmost back teeth (two on each jaw) come 
between the twenty-fourth and thirtieth month. At one year 
there should be six teeth. At one and one-half years twelve 
teeth, at two years sixteen, and at two and one-half twenty 
teeth. 

Although too much stress is commonly laid upon the digestive 
symptoms produced by the eruption of the teeth, there is no doubt 
that there is some connection between the cutting of the teeth and 
the various digestive disorders which usually occur at this time. 
At such times digestive disturbances which otherwise would be slight, 
are very apt to be severe. 

It is, however, true that such digestive upsets are more often 
due to improper feeding than simply to dentition. At such time 
there may be fretfulness, increased drooling, and often a low grade 
of fever. The child puts his hand in his mouth ; the gums are red 
and swollen, sleep is interrupted; the appetite is lessened and the 



238 CARE OF THE BABY AFTER BIRTH 

presence of curds in the stools indicate a decided interference with 
digestion. 

NURSING AT THE BREAST 

After the mother has rested six to eight hours after childbirth, 
the baby may be put to the breast once in four hours for the first 
two days. After this the baby should nurse every two hours from 
seven a. m. until nine p. m., and twice during the night (two a. m. 
and five a. m.). 

The baby should nurse at both breasts at each feeding, and should 
not be allowed more than twenty minutes for the whole nursing. 
While nursing the left breast the baby is held on his right side 
with his head resting on the left arm of the mother while the 
mother lies on her left side. The reverse is true when the baby 
nurses the other breast. 

When the mother is able to sit up she should lean slightly for- 
ward and raise the breast with the fingers of the free hand to keep 
the weight from pressing against the baby's nose when nursing. 

The baby should never sleep in the same bed with its mother. 
The mother may lie on the baby and she will be likely to nurse it too 
often. 

BAD HABITS 

MASTURBATION 

This will be considered in the Chapter on Sexual Hygiene. 

SLEEPLESSNESS 

The newborn babe should sleep nine-tenths of the time ; an infant 
of six months should sleep two-thirds of the time if the digestion is 
good and the health normal. 

The early habit of not feeding the baby after ten a. m. until 
Hve or six a. m. will do more than anything else to encourage sleep 
during the night. Eocking the baby to sleep and the use of the 
rubber nipple or pacifier are not to be recommended. Indigestion 
and overfeeding cause discomfort and sleeplessness. 



FEEDING OF INFANTS FROM THE BOTTLE 239 

If babies are taken up as soon as they cry they will not acquire 
the habit of sound sleep. A nervous temperament or excitement 
before bedtime will interfere with sleep. Insufficient fresh air, 
or too much or too little covering are inimical to sleep. Finally, 
general ill health or special diseases are common causes. 

SUCKING 

Sucking the thumb, blanket, or fingers, is detrimental to babies. 
Change in the shape of the mouth or fingers, infection of the mouth, 
and excessive flow of saliva which interferes with digestion, result 
from this habit. For this reason the use of the blind nipple, or 
pacifier, is inadvisable. 

Placing mittens on babies and pinning their sleeves to their 
sides during sleep will prevent it. N"ail biting is more apt to occur 
in nervous children and should be stopped. Dirt eating is seen 
in children as a result of various diseases. 

BED- WETTING 

After three years of age bed-wetting is abnormal. To prevent 
it give no fluid to the child after four p. m., and take him up at 
ten p. m. so that he can use the vessel. If the habit persists, a 
doctor should be called upon for advice. 



FEEDING OF INFANTS FROM THE BOTTLE 

When a mother is unable, for any reason, to nurse her baby, 
the infant may usually be safely reared on cow's milk, so modified 
as to make the milk more suitable for the infant. Such feeding 
can be more intelligently directed by a doctor with experience in 
the care of children, but when such a doctor is not available, the 
mother or nurse should be able to take upon herself the task by 
following directions with care. 

When one compares the composition of human and cow's milk 
one sees that cow's milk contains almost three times as much proteids, 
only half as much sugar, and about the same amount of fat as 



240 CAEE OF THE BABY AFTER BIRTH 

human milk. The proteids are represented by the curd of skim 
milk, which separates on souring. 

APPROXIMATE COMPOSITION OF COMPOSITION OF WOMEN'S MILK 

COW'S MILK 

Fat 4 per cent. Fat 4 per cent. 

Sugar 4 " " Sugar 7 " " 

Proteids or curd 4 " " Proteids \y 2 " " 

The fat separates from milk and is found in the cream. There 
is about the same amount of sugar in skim milk and cream, i^ow 
hitherto the attempt has been made to modify cow's milk so that it 
will resemble human milk in composition; that is, to add cream to 
cow's milk, to increase the fat, and then dilute this mixture with 
water to lessen the proteids. 

For example, suppose we use the upper half of a quart bottle 
of milk which contains ten per cent, of fat — while the proteids are 
unchanged ; then to every ounce of this we add two ounces of water. 
This would give us a mixture containing three and one-third per cent, 
of fat and one-third of the normal percentage of proteids (one- 
third of four), or one and one-third per cent, of proteids — which 
would somewhat resemble human milk in composition. Then sugar 
would be added, as normal cow's milk is deficient in sugar, and 
when diluted with water would be greatly wanting in this ingredi- 
ent. This has been the general principle of feeding babies in this 
country, but recent knowledge has brought about a change. 

It used to be thought that the proteids or curd of cow's milk 
was the difficult part for infants to digest; it is now known, on the 
contrary, that the fat is most difficult of digestion, and that the 
apparent curds in the bowel discharges of infants are in reality a 
kind of soap formed in the bowels by undigested fat and alkaline 
digestive juices. This has led to the use of less fat in infant's milk. 

It is also commonly taught that lime water should be added 
to milk because human milk is alkaline and cow's milk soon becomes 
acid. As a matter of fact, recent experiments show that such 
an addition does not increase the digestibility of milk. It has been 
found, however, that the addition of some starchy matter to milk. 



FEEDING OF INFANTS FKOM THE BOTTLE 241 

as barley water and some of the malted foods, as malted milk and 
Mellin's food, does increase its digestibility. Some milk sugar may 
be added also, to bring the percentage nearer that in human milk, 
but this is not necessary. 

There is no question that cow's milk is less readily digested and 
assimilated by infants than human milk because the milk of an ani- 
mal is adjusted by nature to the needs of her young. The calf 
attains maturity in one-sixth the time required by the human being, 
and its need of proteids, which build flesh and bone, are great. 
The calf's stomach is much more complicated and capable of digest- 
ing in its four compartments food wholly unfit for the human being. 

But, notwithstanding these drawbacks, babies will flourish on 
cow's milk properly prepared, while some calves will actually die 
on their own mother's milk — in the case of cows giving unusually 
rich milk, as some Jersey and Guernsey cows. 

The most essential difference between human and cow's milk is 
that human milk is free from germs as it leaves the breast, whereas 
cow's milk teems with them. The germs in cow's milk are derived 
from disease of the udder, dirt of the cow, especially manure and 
dirty utensils, and also from contamination with human beings in 
handling the milk — which is a most excellent food for germs to 
grow in. 

Thus from the cow the germs of tuberculosis find their way 
into milk, and also those germs from manure which are wholly 
responsible for the infant mortality from diarrheal diseases and 
so-called cholera infantum. Moreover, epidemics of tonsillitis, af- 
fecting many hundreds of persons, are caused by milk from cows 
with diseased udders. Through contamination of milk by persons 
employed to handle it, typhoid fever, diphtheria, and scarlet fever, 
are very commonly derived. 

In New York to-day the health commissioner believes typhoid 
fever to be chiefly acquired from contaminated milk. In Boston, 
from 1907 to 1911 inclusive, the health authorities found 4,095 
cases of disease caused by milk, as follows: 1,559 cases of scarlet 
fever; diphtheria, 72 cases; typhoid fever, 400 cases; and 2,064 
tonsillitis cases. 



242 CARE OF THE BABY AFTER BIRTH 

Milk is unquestionably the chief cause of infant mortality. Dr. 
Goler, in Rochester, X. Y., by supplying clean milk to infants, re- 
duced the average mortality in babies under one year, in July, 
from 1,000 deaths to 113 deaths, and to-day Rochester has the lowest 
infant mortality in the country, with the exception of Seattle. 

A large percentage of tuberculosis in children is derived from 
milk. Rosenau states that from one-fifth to one-fourth of the tuber- 
culosis of infancy and childhood is caused by milk. Theobald Smith 
concludes that one-half the cases of tuberculous glands in children 
are derived from contaminated milk. About ten per cent, of the 
samples of milk in our large cities contain the germs of tuberculosis 
derived from that disease in the cow. 

The case against cow ? s milk is therefore sufficiently proven. How 
shall we avoid its dangers \ There is only one certain method, and 
that is cooking. The more milk is heated the more is it altered. 
It has been found that even pasteurized milk fed exclusively for sev- 
eral months to babies may cause malnutrition, scurvy or rickets from 
destruction of unknown substances, called vitamines. By giving 
orange juice (containing vitamines") daily to infants absolutely no 
harm will result from feeding pasteurized or boiled milk. 

For it is known that boiling does alter the milk chemically and 
physically in certain ways, and it is admitted that it is usually 
best to heat milk only to that point at which the germs are killed, 
with least alteration in the character of the milk ( this tem- 
perature is 145 : F.), when milk is kept at this point for thirty 
minutes. 

Such heating followed by rapid cooling is called pasteurization. 
Only pasteurized milk should be given infants or children. 

True, there is certified milk, that milk which is the cleanest 
possible to produce and which has led to great reduction in disease. 
But even in certified milk there is chance for contamination with 
human beings not known to be sick, but "carriers" of disease, and 
occasionally cows with tuberculosis are found in certified herds. 

In fact, epidemics of scarlet fever have originated from certified 
milk, and the author has known of three deaths in infants from 
acute forms of tuberculosis due to the same supply of certified milk 



FEEDING OF INFANTS FROM THE BOTTLE 243 

and occurring at about the same time. In this herd about twenty 
per cent, of the cows were found to be tubercular. Of course this 
is a rare and unfortunate occurrence. 

But from all that has been said it will be realized that raw cow's 
milk of any kind is far from a safe food, especially for infants 
living wholly upon it. While the most eminent authorities have 
found that the germs of all the special diseases are killed in milk 
heated to 145° F. for thirty minutes, yet there are many other varie- 
ties of germs in milk that survive this heating. These in large 
quantity may be harmful, and the products of the killed germs may 
also be harmful, so that it is always advisable that the milk be 
as clean as possible even if pasteurized. The ideal milk for infants 
is pasteurized certified milk. ■ 

There is no need for a special apparatus to pasteurize milk in, 
although the Freeman pasteurizer is an excellent one. After the 
nursing bottles have been properly cleaned and boiled, the proper 
amount of milk is placed in each bottle and a sufficient number of 
filled bottles for twenty-four hours' feeding, stopped with absorbent 
cotton, are placed in cold water in a kettle on a stove. The water 
should come well up to the level of the milk in the bottles, or as 
far as possible, and yet have the bottles stand firmly. 

A perfectly clean dairy thermometer is then placed in one of 
the bottles of milk and, when the milk reaches 145° F., the vessel 
and contents should be taken off the stove and the whole covered 
with a blanket and allowed to stand for one-half hour undisturbed. 
If the temperature falls during this time the kettle should be kept 
on the back of the stove. The bottles are next removed and quickly 
cooled in cold water and placed in the ice chest. 

Pasteurized milk should not be bought for babies, as the com- 
mercial pasteurization may be unreliable. 

In a general way it may be said that milk from one cow is not 
so good for an infant as that from a mixed herd on account of 
variations in composition. There is a prevailing idea that any 
milk from a nearby farm is good, but farmers not engaged in selling 
milk in the city are apt to be poorly supplied with the machinery 
and facilities for properly handling it. Of course if milk can be 



244 CAEE OF THE BABY AFTER BIRTH 

obtained fresh, so much the better, if it has been drawn in a cleanly 
manner. It should be cooled down to below 50° F. immediately or 
within two hours after milking. 

The household should be entirely separated from the dairy, Imd 
neither the utensils or milk should ever be brought into a living 
apartment in the production of safe milk. Milk for infant feeding 
should be bought only in quart glass bottles, unless obtained from 
a nearby source, when the milk may be poured from a can into such 
bottles, which have been boiled, and placed in ice water to cool, 
before being set away in a refrigerator. The bottle may be covered 
by a clean, inverted jelly glass. 

FEEDING DURING THE FIRST WEEK 

Feeding for the First Twenty-four Hours. — Row as to the pre- 
cise manner of using cow's milk for infants. During the first 
twenty-four hours of the baby's life nothing but boiled water heated 
to the temperature of the body, with a pinch of milk sugar, should 
be given — to the amount of three tablespoonfuls every four hours in 
a nursing bottle. 

Feeding after the First Twenty-four Hours. — After this time 
skim milk may be fed pure. This should be first pasteurized, as de- 
scribed above, or boiled for one-half hour in a double boiler during 
the first three months, boiling the quantity of milk required for each 
twenty-four hours' feeding at one time each day. 

The reason for boiling the milk the first three months is that 
then digestion is the weakest, and boiling milk has been shown 
to make it more digestible by causing the milk to form softer curds 
in the stomach and by preventing the fat globules in milk from 
coalescing, as otherwise will occur. 

Skim milk is used the first week because at that time woman's 
milk is naturally poor in fat and sugar. 

FEEDING DURING THE SECOND WEEK 

At the end of the first week a mixture consisting of one-third 
whole milk and two-thirds skim milk mav be used. This whole milk 



FEEDING OF INFANTS FROM THE BOTTLE 245 

should be milk poor in fat or that containing only three per cent, of 
fat. 

Now ordinary milk contains, as we have seen, about four per 
cent, of fat. Rich milk contains five per cent, of fat. The amount 
of fat in the milk may often be ascertained from the milkman, but 
more accurately by telephoning the city chemist, who is required to 
examine all samples from venders of milk, at regular intervals. 
In the country a creamery will determine the fat in milk at slight 
expense. If one cannot readily ascertain the amount of fat in the 
milk, it is safer to consider it richer than it probably is before 
diluting it. 

The following directions will enable one to make a milk contain- 
ing three per cent, of fat from a richer milk. From milk con- 
taining four per cent, of fat remove the upper one and two-third 
ounces of cream from a quart bottle, after it has stood four hours 
or more. Remove the upper two and one-half ounces from milk 
containing four and five-tenths per cent, of fat, and remove the 
upper three and one-half ounces from milk containing five per 
cent, of fat, to reduce it to milk containing three per cent, of fat, 
which is what is spoken of hereafter as whole milk. No richer 
milk should be fed a baby. 

The skim milk is obtained by dipping off the cream, with a 
Chapin dipper, from the top of a bottle after the cream has fully 
risen. 

FEEDING DURING THE FIRST SEVEN MONTHS 

At the end of the second week one-half of skim milk and one- 
half whole milk may be used; at the end of the third week three- 
quarters whole milk and one-quarter skim milk; and at the end of 
the first month whole milk containing three per cent, fat may be 
fed undiluted. 

It must not be expected that the baby will begin to gain with 
this method of feeding until the third week or so, but it is safer 
than using the richer mixtures. In some cases the digestion is so 
poor that artificial digestion of the milk may be necessary, as 
described below. 

The feeding with whole milk may be pursued until the infant 



246 



CARE OF THE BABY AFTER BIRTH 



is seven months old when the addition of cereal food is advisable. 
This method of feeding is exceedingly simple as compared to that 
hitherto in vogue, and is based on the most recent investigations and 
upheld by the United States Public Health Service and large ex- 
perience. Cow's milk for babies must always be pasteurized (pp. 
242-3) or boiled, and orange juice must also be given (p. 255). 
Whole milk contains enough natural sugar. When milk is much 
diluted, milk sugar or malt sugar to the amount of one level table- 
spoonful in the twenty-four-hour milk mixture may be added. Pep- 
togenic milk powder contains milk sugar. 

The quantity of milk at each feeding and the intervals between 
feedings are shown in the following table: 

Schedule for feeding healthy infants during the first year* 



Age. 



Interval 


Night 


Number 


Quantity 


between 


feedings 


of f eed- 


for 


meals 


(10 p. m. 


mgs in 


1 


by day. 


to 7 a.m.). 


24 hours. 


feeding. 


Hours. 






Ounces. 


3 


1 


7 


1H-2M 


3 


1 


7 


2 -4 


3 


1 


7 


3 -4V 2 


3 


1 


7 


3M-5 


3 





6 


4M-6M 


4 





5 


6M-9 



Quantity 

for 

24 

hours. 



Second to seventh day 
Second and third weeks . . . 

Fourth to ninth week 

Tenth week to fifth month . 
Fifth to seventh month 
Seventh to twelfth month . . 



Ounces. 
10-17 
14-28 
21-31 
24-35 
27-39 
33-45 



* From "Care and Feeding of Children," L. Emmett Holt, M. D. 



Some doctors feed at four-hour intervals from the beginning, but 
in many cases the infant will not get sufficient nourishment to thrive 
with these longer intervals. 

After the third week there will be one feeding between ten 
p. m. and seven a. m. ; but often a more convenient arrangement 
may be made so that the infant may be allowed to sleep be- 
tween the last feeding at nine or ten p. m. and the first feeding 
early in the morning at five or six a. m., and this custom may be 
established by habit and by only giving warm water in the middle 
of the night if the baby awakes. 

The amount 9f cow's milk in twenty-four hours required by 



FEEDING OF INFANTS FROM THE BOTTLE 247 

an infant is that equal to one-seventh of the body weight — up to 
three months of age; and after that an amount equal to one-eighth 
of the body weight. Thus if a baby one week old weighed seven 
pounds, he would require sixteen ounces, or one pint, of whole cow's 
milk in twenty-four hours. A baby of four months weighing twelve 
pounds would require one-eighth of this, or twenty-four ounces of 
whole milk (three per cent, fat) in twenty-four hours. 

The greatest trouble in feeding infants artificially will occur 
in the first few months. If babies have been on the breast for some 
months and then are fed cow's milk, it is better to begin the bottle 
feeding the same way we begin with infants in the first week, i. e., 
with skim milk and gradually add the whole milk until a whole 
milk containing three per cent, fat, as above, is fed. 

When skim milk does not agree with newborn babies and there 
is much restlessness and crying, and the baby is constipated, and the 
movements are clay-colored or green, it may be necessary to increase 
the digestibility of the milk by adding to it what is called Pepto- 
genic Milk Powder. This partially digests the milk before it is 
taken. 

One need not follow the directions on the maker's bottle, but 
add one measureful, mixed with a little cold water, to the skim 
milk for twenty-four hours' feeding. The milk should be previously 
warmed to about the temperature of the body in a double boiler, 
and then the milk should be allowed to stand in the boiler off the 
stove, and the powder added and stirred in with a clean spoon. After 
the powder has been in the milk for ten minutes the boiler should 
be placed on the stove again and the milk boiled and then cooled 
in the double boiler in cold water, and poured into the individual 
nursing bottles which are to be used for the next twenty-four hours. 
It is not necessary to use more than one measureful of the powder 
even if the amount of milk required is greater than that given in 
the directions for the use of the powder, and the milk need not be 
boiled more than a minute. 

If this predigested whole skim milk does not agree with the 
infant, one may begin by using the powder in half skim milk and 
half water, adding an ounce more of skim milk daily in place of 



248 CAEE OP THE BABY AFTER BIRTH 

an ounce of water. When all skim milk is used, then one may 
begin to add whole milk in place of skim milk, as advised in the 
feeding of normal infants during the first month. 

After using the powder for several months it may be dropped 
without any bad effect in most cases. The writer has had great 
success in feeding babies with delicate digestion by this plan. 

In cases of difficult digestion where the milk with the peptogenic 
powder does not agree, the milk may be diluted with barley water, 
prepared as directed in Chapter XIV, and the powder discon- 
tinued. 

Of course the only proper and sensible procedure consists in em- 
ploying a doctor to prescribe the food for all infants. 

FOOD IN ADDITION TO MILK ALLOWED THE FHiST YEAE 

Only quite recently has it become generally recognized that 
infants may digest starchy food perfectly in the early months. 
Ordinarily the cereals are not added to milk until the seventh 
month, but they may be used as early as the second month if the 
pure milk does not seem to agree. They prevent hard curding of 
milk in the stomach and overcome constipation. 

When begun at the second month only a few ounces should be 
used to replace the same amount of milk in the twenty-four-hour 
supply. If this agrees well, the amount of cereal may be increased 
until it forms one-third of the whole of the food. The flour of 
barley, wheat or rice is used. Robinson's or Brooks' barley flour is 
most often given. 

UTENSILS NECESSARY FOR PREPARING INFANTS' FOOD 

One dozen round or flattened nursing bottles 

One dozen black rubber nipples 

One eight-ounce measuring glass 

One brush for cleaning bottles 

One one-ounce Chapin dipper, for removing cream from top of a quart 

milk bottle 
Some absorbent cotton for stoppering nursing bottles 
Two wide-mouthed bottles for baking soda and boric acid. 



DETAILS OF PREPARATION OF MILK 249 

One tall quart cup in which to heat separate nursing bottles before each 

feeding 
One ordinary kettle for holding bottles necessary for twenty-four hour 

use 
One small glass funnel for filling nursing bottle. 

Note. — The nursing bottles should have a gradually sloping neck so as to 
be easily cleaned. Those bottles (Hygeia) without any neck and having a wide 
nipple are good, but the nipples are more expensive. 

The black rubber nipples referred to in the above list should either be 
straight or with ball-like top, with three small holes through which the milk 
will just trickle. 



DETAILS OF PREPARATION OF MILK AND CARE OF 

UTENSILS 

In order that cream should properly rise on milk it should stand 
in the ordinary one-quart glass milk bottle four or five hours in 
a cool place. If the milk is delivered in a glass milk bottle and 
the cream has already risen it may be removed at any time, or enough 
to make a three per cent. milk. 

When the skim milk is to be used the cream should all be 
dipped off with, the milk dipper, or the skim milk should be drawn 
off through a siphon made of a bent glass tube with one end four 
inches longer than the other. 

It is difficult, however, to keep these glass tubes clean and the 
dipper is advised. Pouring off the cream from the bottle is not to be 
done because the cream and milk become mixed in the process. 
Enough milk should be placed in bottles at one time to last for 
twenty-four hours. 

That there may be no misunderstanding as to details we will 
suppose that we are beginning to feed a newborn babe. We do 
not begin to feed milk until the second day. Before this time 
the baby should receive only sugar water, as described above. 

Supposing that we begin with the feeding of skim milk, as 
advised above, we must first separate the cream from a quart bottle 
from the skim milk and boil the skim milk as described. Then, ac- 
cording to our table above, there will be ten feedings in twenty- 
four hours of one to one and one-half ounces each. Eleven bottles 



250 CARE OF THE BABY AFTER BIRTH 

(as the contents of one may be spilled accidentally), each containing 
one and one-half ounces, or sixteen and one-half ounces, of skim 
milk for the twenty-four hours should be prepared. 

In this case all that is necessary is to pour the boiled milk, 
after it has been cooled in cold water, through a glass funnel into 
the nursing bottles to the point marked one and one-half ounces, 
plugging the mouth of each bottle with absorbent cotton, and placing 
the bottles on ice. 

The bottles may be kept in racks sold for the purpose, or placed 
in a bread tin to keep them from toppling over. It is always wise 
to taste the milk before making up the twenty-four hour quantity 
to be sure that it is not sour. 

Feeding is begun at six a. m. and continued with regularity every 
two hours till ten p. m. When about to feed the baby, the bottle 
is taken from the ice and warmed by standing it in a tall quart 
cup of warm water. The temperature of the milk should be 100° 
F., and it should feel slightly warmer than the temperature of the 
body. 

A flannel cover should be used to keep the milk warm while 
the baby is nursing. The nipple should be tested after it is at- 
tached to the bottle to see that the milk flows properly, that is, drops 
rapidly from the bottle. A baby should not be allowed to nurse more 
than twenty minutes at a time; at the end of this period the bottle 
should be taken away. Jouncing or disturbing the baby after 
eating does harm in causing vomiting and indigestion. The baby 
should be placed quietly in his crib. 

In regard to the quantity of milk suitable for each feeding, it 
may be said that the larger amounts may be given to the larger 
babies having strong digestions. If a baby evidently wants the 
larger amounts given in the table above (p. 246) and the food 
agrees with him, it will be proper to continue with the larger quan- 
tities. 

During the first two months babies should be held in the arms 
of the nurse when fed, except at night. After this time the baby 
may lie on his side in a crib while the nurse holds the bottle bottom 
side up. An infant must be wakened at the appointed time for 



DETAILS OF PEEPARATION OF MILK 251 

feeding during the day but may sleep as long as he will without 
being fed at inght. 

After each nursing the bottle should be immediately rinsed in 
water and left standing, filled with water containing one-half tea- 
spoonful of baking soda. Once daily all the bottles should be washed 
inside with brush, soap and hot water, and then boiled for twenty 
minutes in plain water. To prevent new bottles from being broken 
by boiling they should be placed in cold water, and then the water 
should be brought to the boiling point, and the bottles allowed to 
remain in the water until it again becomes cold. This process is 
called annealing. 

The nipples, when not in use, should soak in a solution of boric 
acid (as much of the acid as the water will dissolve) until such 
a time of day as they may be all turned inside out and washed with 
hot soapsuds. They may be boiled for five minutes when new but not 
after this, as the rubber will be ruined. 

All vessels which come in contact with the baby's milk must 
be washed and boiled before use. This category includes the two- 
quart bottle for mixing skim milk and whole milk, the dipper for 
removing cream from milk, the spoon used for mixing the food, 
etc. Any portion of the food left in the bottle after nursing should 
of course be thrown away. 

The difficulty of feeding babies lies in the fact that no two 
babies are alike in their response to food. It is always safer to 
underfeed than to overfeed. The mother thinks only of getting 
more nourishment into her baby, especially if the infant is ailing 
and losing weight. But an amount of food less than necessary 
for the baby's requirements is infinitely better than overfeeding, 
which may upset the digestion so that no food will be tolerated for 
a considerable period. 

As long as the baby is gaining satisfactorily and the bowel dis- 
charges have a normal yellow color, are of proper soft consistency, 
without curds, and the number is not above two or three in twenty- 
four hours, the food is satisfactory and need not be changed. 
But if the gain in weight is not satisfactory, as shown by weekly 
weighings, and the bowel discharges are normal, but the baby 



252 CAEE OF THE BABY AFTER BIRTH 

is crying for more food, then it is high time to increase the 
food. 

On the other hand, if the baby is overfed he may vomit, be 
fretful, and have colic and wind ; the bowels will be constipated and 
the discharges pale and dry; the appetite may be poor or good and 
the baby may lose weight. Then is the time to cut down the diet. 
If skim milk alone is taken it may be necessary to dilute this a 
third or a half with water. If whole milk, or whole milk and 
skim milk, are being fed, the diet may be reduced to skim milk 
alone. This should be continued for a few days until the milk 
becomes normal again and the milk should slowly be increased in 
strength. It is not advisable to increase the strength of the food 
oftener than once in a few days. 

When the infant is overfed it is wise to give a teaspoonful of 
castor oil at the same time the food is reduced. In the case of 
severe vomiting and diarrhea in babies, all milk should be stopped 
for twenty-four hours and only barley water, whey, chicken broth, 
or white of egg and water should be given; the bowels should be 
washed out with injections of salt and water (one teaspoonful to 
the pint). Milk should not be given again until the bowel dis- 
charges begin to look normal and then only boiled skim milk should 
be employed for several days. If the baby's appetite is poor, but 
he seems otherwise well, the intervals between the feedings should 
be increased by an hour or two. 

If the baby is stricken with fever or acute disease of any kind, 
as measles, a bad cough, etc., the food should be diluted with one- 
third to one-half of boiled or barley water. 



CHAPTEE XIV 
FOOD FOR INFANTS AND THE SICK 

Including barley and oatmeal water, barley gruel, beef juice, orange juice, 
water, egg-white, coddled egg, meat broths, albumen or egg water, whey, 
scraped beef, beef tea, peptonized milk, Junket or milk curd, milk por- 
ridge, soft custard, egg nog, clam broth, oyster broth, condensed milk, 
patent or proprietary foods. Diet for children from first to sixth year. 

As many of the following receipts are useful for sick adults as 
well as babies we will include them in a separate chapter. 

Barley and Oatmeal Water. — Stir one level tablespoonful of 
Brooks' barley flour into cold water to make a thin paste, and add 
this gradually to one pint of boiling water in a double boiler; boil 
twenty minutes. 

Sometimes only one teaspoonful of barley is used in the beginning 
for infants. Whole barley is sometimes employed; it is washed 
and soaked in cold water over night. This is drained off in the 
morning and fresh cold water is added (one and a half tablespoonfuls 
to the quart), and the whole boiled for four hours in a double boiler, 
down to a pint, adding water as need is indicated. Strain through 
muslin. 

Oatmeal water is made in the same way as barley water except 
that the cooking should be done for an hour, and enough water 
added from time to time to make up for that which has been evapo- 
rated. It may be used instead of barley water for infants, and 
is beneficial in constipation. Kice or wheat flour may be cooked 
and used in the same way as barley for infants. 

Barley water may be fed infants first in the weaker receipt, 
noted above, and then gradually increasing its strength to one table- 
spoonful to the pint. The milk may be diluted one-third, and when 

253 



254 . FOOD FOR INFANTS AND THE SICK 

this is done the whole cow's milk may be used without removing 
any cream. Even the richest milk would contain but a trine over 
three per cent, of fat when so diluted. 

When this does not agree with infants the starch may be par- 
tially digested or dextrinized. The cereal water is made as ' de- 
scribed and, when cooled to blood heat, one teaspoonful of taka- 
diastase or of cereo or Forbes' diastase (obtainable of a druggist) 
is added to a pint, which is allowed to stand for fifteen minutes 
before being added to the infant's milk. The starch is thus par- 
tially digested, and the mixture is suitable for infants with delicate 
digestion. 

Barley Gruel. — Two tablespoonfuls of barley flour are mixed 
with cold milk in a double boiler into a thin paste and stirred into 
a quart of boiling milk, with sufficient salt, and cooked for two 
hours. Instead of milk, barley flour may be added to the broth 
in the same proportion and cooked for one-half hour and strained. 
These receipts are suitable for sick children or adults. 

Another easily digestible and palatable receipt for adults is made 
by beating a whole egg and adding a tablespoonful of sherry, a tea- 
spoonful of lemon juice, and sufficient sugar and powdered nutmeg 
to a whole cupful of hot gruel. Gruels of wheat and oat flour may 
be made in the same way. 

Beef Juice. — Broil slightly some steak from the rump or upper 
part of the round for one or two minutes and squeeze out the 
juice with a lemon squeezer, press, or potato ricer, into a warmed 
cup. Beef juice may be given to normal babies after the eighth or 
ninth month. For pale and anemic infants it may be begun as 
early as the sixth month. 

It is given with an equal amount of water about five minutes 
before the regular milk feeding. Beginning with a teaspoonful of 
beef juice it may be gradually increased every three or four days, 
until at the end of two or three weeks two tablespoonfuls are given 
once daily at one time. 

One-half pound of lean meat passed through the Enterprise 
Chopper may be made into a flat mass and broiled until slightly 
brown and the juice extracted with a press. The juice may then 



FOOD FOR INFANTS AND THE SICK 255 

be mixed with an equal part of barley water. This forms a good 
diet with broths for infants with diarrhea who cannot take milk. 
Only enough juice should be prepared for one feeding at a time. 
Beef juice is excellent for adults with fevers and digestive troubles. 

Orange Juice. — Milk for all babies (who are not nursing at the 
breast) should either be pasteurized or boiled and, at the same time, 
orange juice should be given to prevent scurvy, rickets and malnu- 
trition that may result from heating the milk (destruction of vita- 
mine, pp. 242-3), and also to secure a laxative action. 

Beginning when the baby is three weeks old one teaspoonful of 
freshly squeezed orange juice should be given three times daily — 
gradually increasing the amount to three tablespoonfuls three times 
a day. Some doctors boil the orange juice a few minutes, but this is 
not essential. 

Water. — An infant should have pure, cool water to drink from 
the time of its birth, whether fed from the breast or bottle. The 
water, unless analysis has shown it indubitably pure, should be boiled 
daily and kept cool in a fruit jar. During the first year water 
should be given three times daily with a spoon, cup or nursing- 
bottle. From the beginning of the second year from one to four 
ounces should be given between meals. 

Egg-white — Coddled Egg. — Boiling water is taken from the 
stove and an egg is placed in it ; at the end of ten minutes the white 
of the egg is softly coagulated. This may be used in place of beef 
juice for variety in the diet of infants after the sixth month. One- 
half the egg-white may at first be given once daily and, at the end 
of a week, the whole white may be taken. 

Broths, albumen water, and whey, are often given babies alter- 
nately in place of milk during an attack of digestive trouble with 
vomiting or diarrhea. 

Veal, Chicken, Beef, or Mutton Broth. — The flesh of a knuckle 
of veal, two pounds; or a chopped chicken, bones, and all; or two 
pounds of round of beef or neck of mutton are added to a quart of 
cold water and soaked for half an hour in a tightly covered agateware 
kettle. 

The meat should be wiped off with a damp cloth, and cut into 



256 FOOD FOR INFANTS AND THE SICK 

small bits, and the bones broken into small pieces. Then after 
soaking the meat in cold water the kettle is placed on the fire and 
the broth brought slowly to the boiling point. This should boil but 
a few moments, and then the kettle should be moved to the back of 
the stove and allowed to simmer (170°, 180° F.) for two to six 
hours, or until the meat is colorless and in rags. Strain, and, when 
cool, remove the fat. Heat in a double boiler when this is used, 
and flavor to taste. 

Two tablespoonfuls of barley, flour may be added to a quart of 
broth to increase its value (See Barley Water). For invalids vege- 
tables (onions, carrots, etc.) may be cut up and added an hour 
before the soup is taken from the fire. When it is desired to 
thicken soups for invalids, as chicken soup, two teaspoonfuls of flour 
should be stirred slowly and thoroughly into melted butter in a cup 
over the fire. Then enough soup is poured into the cup to make a 
very thin mixture and this is slowly stirred into a pint of boiling 
soup. 

Broth may also be mixed with an equal quantity of milk, and the 
whole brought to a boil and thickened, as described. Chicken broth 
is agreeable served in this manner. Only the plain unthickened 
broths, veal, chicken, beef or mutton, however, are given infants. 
They may be taken in a nursing bottle. 

For invalids a strong beef broth may be made from one pound 
of beef and one pound of bone cooked, as described above, eight 
hours in one quart and one-half pint of water. When strained 
off and allowed to cool, the jelly may be eaten or the broth heated 
in a double boiler but not to boiling. When meat is not obtainable 
a nutritious broth may be made by stirring a raw egg into water 
as hot as can possibly be swallowed (140° F.) and flavoring with 
salt or a little beef extract; or the yolk and white of an egg are 
beaten separately and the yolk stirred in hot broth, which is flavored 
with salt, and then the white is stirred in and the whole reheated 
as hot as can be swallowed. Liquids can be taken as hot as 140° 
F., but 122° F. is a more agreeable temperature. 

Albumen or Egg Water. — Stir the white of one egg into one- 
half pint of water which has been boiled and cooled. Albumen 



FOOD FOR INFANTS AND THE SICK 257 

water may be taken from a nursing bottle by infants and may be 
sweetened with a teaspoonful of milk sugar. 

White of egg is very frequently given to adults in fevers and 
when the digestion is weak. It is given in various ways: the white 
of an egg may be beaten with a cup of cold water and flavored 
with a little lemon juice or sherry and sugar. 

Whey. — Warm one pint of pasteurized milk to blood heat, add 
a pinch of salt, a teaspoonful of sugar, and two teaspoonfuls of 
liquid rennet, or a rennet tablet dissolved in water, or two teaspoon- 
fuls of essence of pepsin. 

Allow the milk to stand in a warm place until a complete curd 
forms; then beat the curd with a fork and strain off the liquid, 
or whey, through muslin. If the curds are well beaten the whey 
is richer in fat. Follow the directions on the rennet bottles as 
different preparations vary in strength. To make it more nourishing 
stir the white of an egg into a glass of whey. 

Broth, albumen water and whey are alternated and given to 
infants at the ordinary times of milk feeding, which they should 
replace when there is vomiting and diarrhea. 

For adults whey may be separated with lemon juice or sherry, 
which gives it an agreeable flavor. One cup of milk is boiled in 
a double boiler ; two tablespoonfuls of lemon juice or three of sherry 
are added and the milk is cooked, without stirring, until it curdles. 
Strain through cheesecloth and add sugar. This may be served hot 
or cold. 

Scraped Beef. — Lay a piece of tender, raw steak (free from 
fat), one-half an inch thick, on a board and scrape away the 
pulp with a sharp knife until only tough, stringy fibers are left. 
The meat may also be prepared by using a grater or Enterprise 
Chopper, and then by pounding the pulp in a mortar and passing 
it through a sieve, and seasoning with salt. 

It may be fed babies, after rubbing the pulp with water until it 
has the consistency of fine cream, giving a teaspoonful at a time. 
For adults the scraped pulp may be made in cakes one-half an inch 
thick, seasoned, and broiled two minutes, and served on buttered 
toast. 



258 FOOD FOR INFANTS AND THE SICK 

Beef Tea. — This is made as recommended for broth. One-half 
a pound of fat-free rump or round steak is cut into small pieces 
and placed with a cup of cold water in a double boiler for fifteen 
minutes. Cold water is then placed in the outer part of the boiler 
and the whole should be set on the fire. 

The cooking should be done slowly and the beef tea should be 
heated to a point not above 150° F. for two hours. Beef tea is 
strained off, but the more fine the particles of meat in it the better. 
Fat should be removed when cold, or a piece of bread may be laid 
on top of the beef tea to absorb it. It is even better to cook beef 
tea six hours when there is time. 

To make beef tea rapidly, place one pound of scraped beef, free 
from fat, in a covered enameled saucepan, and pour half a pint of 
boiling water on it ; cover and put on the back of the stove for ten 
minutes. Strain into a tea cup; place the cup in cold water, and 
skim off the fat when cold. Warm and season to taste. 

Beef tea is a stimulating preparation for invalids but does not 
contain much nourishment. It is not given to babies. By sim- 
mering it for many hours there are more particles of flesh, and 
therefore more nourishment in the beef tea. 

Peptonized Milk. — This is useful for babies when they vomit 
milk or do not digest it well, as shown by gray, white, or greenish 
bowel discharges, pain, flatulence, and constipation. 

The peptogenic milk powder is especially prepared to digest 
milk for babies, and therefore contains sugar of milk. But Fair- 
child's peptonizing powders may be used for digesting milk for 
adults, when the digestion is so poor that little food is retained 
in the stomach, and they may also be employed for infants if it is 
not desired to use sugar of milk. The peptonizing powders are 
sold in little glass tubes. The contents of one of these tubes is to 
be rubbed up with a little milk in a cup and then poured into a 
pint of milk, which has been previously heated to the temperature 
of the body (98° F.) in a double boiler. The milk is kept at the 
same temperature for ten to twenty minutes and then, unless to be 
used at once, is immediately boiled or placed on ice. If the milk 
were kept warm artificial digestion would go on until the milk was 



FOOD FOR INFANTS AND THE SICK 259 

bitter and unpalatable. Heating or cooling the milk stops the 
digestion. 

If less than a pint of milk is desired a fraction of the powder 
may be used at a time, according to the amount of milk used. In 
giving the peptonizing powders to babies one-sixth of the contents 
of a tube may be mixed with cold water in a spoon and added to 
each bottle of milk just before feeding the baby. Then the bottle 
is heated to blood heat, as usual, but the powder is allowed to remain 
in the milk ten minutes before the bottle is given to the baby. 

It may be used during the first few months for infants with 
weak digestion, or during attacks of acute indigestion. For infants, 
however, Fairchild's Peptogenic Milk Powder is usually more 
suitable. 

Junket or Milk Curd. — This is made as in the preparation of 
whey with the exception that in this case the curds are not beaten 
to separate the whey, but the curd when formed is cooled in an 
icebox and eaten with sugar and cream and grated nutmeg on the top. 

To increase the nutritive value of the curd a whole egg, beaten 
to a froth with two teaspoonfuls of sugar and of rum, brandy or 
wine, may be stirred into the warm milk before adding the rennet. 
Or two or three tablespoonfuls of boiled coffee or cocoa may be 
added for flavoring to each cup of milk before using the rennet. 

Junket is a pleasant article of food for a convalescent or adult 
with weak digestion or fever, and is used (plain) as a regular addi- 
tion to the diet of infants over a year old. 

Milk Porridge. — Stir one tablespoonful of flour in a saucepan 
with a little cold milk until free from lumps, and then gradually 
add one-half pint of boiling milk while stirring. Boil a few minutes. 

This is very useful for adults and older children with diarrhea, 
eaten with cream and sugar, and may be alterr-ated with boiled rice 
and milk toast. 

Soft Custard.' — Scald a cup of milk in a double boiler. Beat the 
yolk of two eggs with teaspoonfuls of sugar, and salt to taste. Add 
gradually to scalded milk and stir until the mixture becomes creamy 
and free from froth. Remove from fire and cool, adding vanilla, or 
orange or lemon extract. 



260 FOOD FOR INFANTS AND THE SICK 

Soft custard is a very nutritious and digestible dessert for chil- 
dren or invalids, and may be eaten with bread broken into it. 

Egg Nog. — Scald some milk, but do not allow it to boil. Beat 
up the white of an egg to a stiff froth, and then beat in the yolk, a 
little sugar, and two teaspoonfuls of sherry, brandy, or rum. Stir 
the egg into a glass two-thirds full of the cold scalded milk. 

Owing to the richness of the yolk persons soon tire of this and, 
for most invalids, it is best to only use the white of egg with milk. 
The white of egg may be first beaten alone or beaten with the milk, 
and the stimulant, sugar or salt then added. 

Clam Broth. — Scrub and wash a dozen clams thoroughly, chang- 
ing the water several times. Place in a saucepan with two table- 
spoonfuls of water, cover and cook until the shells open. Then take 
the clams from the shells, allowing the water in the shells to run 
into a saucepan. Strain the clam juice from the saucepan through 
two thicknesses of cheesecloth and serve hot with a little butter, 
and bread crumbs. This is an appetizing broth for an adult but 
contains little nutriment. 

Oyster Broth. — Mince one pint of oysters, and add to one-half 
pint of cold water. Let this simmer for ten minutes; skim, strain, 
and serve hot with pepper and salt. This is similar to clam broth 
and may be used for adults with acute indigestion and fevers. 

Condensed Milk. — Unsweetened, sterile condensed milk is an 
excellent substitute for fresh milk when that is unobtainable. Many 
infants have been fed successfully on it, but orange juice should 
always be given with any form of dried or condensed milk (p. 255). 
Carnation milk contains double the percentage of constituents in 
fresh milk, as half the water has been evaporated. It should be 
diluted with 6 parts of water — gradually adding more milk until 
only 4 or 3 parts of water are used. With 3 parts of water it con- 
tains 3 per cent of fat. Mammala is a good substitute for milk in 
powder. Sweet condensed milk contains too much sugar for babies, 
but in emergencies may be given as follows: 1 part in 13 of barley 
water at 1 month; 1 part in 11 of water at 2 months'; 1 part in 10 
of water at 3 months ; 1 part in 8 of water at 4 to 6 months ; 1 part 
with 6 of water for older children. 



DIET FKOM TWELFTH TO FIFTEENTH MONTH 261 

Patent or Proprietary Foods for Babies. — The patent foods are 
not essential, and used injudiciously they have been the cause of 
more disease among babies than any other food except impure milk. 
The strained gruels take the place of these and, if it is desired to 
make them more digestible, taka-diastase may be added. Some of 
the patent foods, as Mellin's food and malted milk, make an excellent 
addition to cow's milk, but the trouble has been that too much re- 
liance has been placed upon the nutritive value of the foods. 

The use of the ordinary cereals, as barley water, is much cheaper 
than patent food and it is wiser to rely upon only such foods as 
may be advised by the doctor. Some of the patent foods are unfit 
for any baby, and all are bad when used unwisely. 

Urging or bribing children to eat, or amusing them while at 
meals, are useless and harmful practices. Such methods will not 
improve a poor appetite and they encourage the tendency to play 
with food. If, when the proper food is placed before a child he 
will not take it or dallies complainingly with it, remove it at once 
and give him nothing between meals, and repeat the same procedure 
at subsequent meals. Hunger will quietly and forcibly accomplish 
what cajoling and talk never will, and the child will come to recog- 
nize the proper times for eating and proper kinds of foods as the 
only ones. 

DIET FROM TWELFTH TO FIFTEENTH MONTH 

At twelve to thirteen months all normal babies should be weaned 
from the bottle and made to take food from a cup or spoon, though 
up to the eighteenth month the child, as a matter of convenience, 
may have the ten o'clock feeding from a bottle. The importance 
of weaning from the bottle at this time is often overlooked, and 
if the child is allowed to continue on chiefly a milk diet for two 
years he will suffer from lack of sufficient solid food and become 
weak and pale. 

Five meals should be given daily — at six-thirty and ten a. m., 
and at two, six and ten p. m. These should consist of milk, which 
should be pasteurized from June first to October first, except that 
at the third meal three to four teaspoonfuls of beef juice, or a cup 
of beef, mutton or chicken broth, or a soft boiled egg and a slice 



262 FOOD FOR INFANTS AND THE SICK 

of toast may be given in addition to half the usual amount of milk. 
The juice of fresh fruit, as orange or peach, should be given once 
daily an hour before the regular time of feeding. 



DIET FOR CHILDREN FROM FIRST TO SIXTH YEAR 

DIET FROM FIFTEENTH TO TWENTIETH MONTH 

Six-thirty a. m.: Six to eight ounces of warm, certified milk, 
pasteurized during the summer months, with two to three ounces 
of oatmeal or barley gruel. 

Nine a. m. : Orange juice, two to three ounces. 

Ten a. m. : One to two tablespoonfuls of oatmeal, hominy, farina, 
arrowroot or barley. The oatmeal or hominy should be cooked three 
hours and strained. This may be given with thin cream and salt. 
The child may also have a glass of milk. 

Two p. m.: A cup of beef, mutton or chicken broth, one soft- 
boiled or poached egg, boiled rice, or one to two tablespoonfuls of 
scraped rare mutton or beef. For dessert, the soft part of stewed 
prunes, baked apple or apple sauce. 

Six p. m.: Eight to ten ounces of milk and one of the cereals. 

Ten p. m. : Ten to twelve ounces of milk. If the baby sleeps 
through the night after the six o'clock feeding the ten o'clock meal 
may be discontinued. 

DIET FROM TWENTIETH TO TWENTY-FOURTH MONTH 

Six-thirty a. m.: Ten to twelve ounces of certified milk, pas- 
teurized in the warmer months. 

Nine a. m. : The juice of one orange. 

Ten a. m. : One of the cereals well cooked but not strained ; six 
to eight ounces of milk. A slice of bread at least two days old. 

Two p. m.: Either soft egg or one tablespoonful of scraped 
meat as above; six ounces of broth, or two to four ounces of beef 
juice, and soft prunes; baked apple or apple sauce. Water, but no 
milk. 



DIET FROM FIRST TO SIXTH YEAR 263 

Six p. m. : Imperial Granum or strained barley in ten to twelve 
ounces of milk. 

Ten p. m. : Ten to twelve ounces of plain milk. 

DIET FROM SECOND TO THIRD YEAR 

Seven a. m.: Cereal, bread and butter, or toast or Graham 
crackers. 

Nine a. m.: The juice of an orange. 

Ten p. m.: A glass of warm certified milk or cup of broth. A 
slice of stale bread, or toast or Graham crackers. 

Two p. m.: A cup of broth, if not given at ten o'clock meal. 
Scraped meat — steak, chop, chicken, beef or lamb. Any of the 
following vegetables : potatoes, baked, mashed or boiled ; boiled rice 
or macaroni with milk; green peas, spinach, or string beans; or 
stewed celery. For dessert : rice pudding, junket, custard, stewed 
prunes, baked apple, or apple sauce. 

Six p. m. : Cereal and milk, milk toast, or bread and milk. 
Ten to twelve ounces of plain milk. 

DIET FROM THHtD TO SIXTH YEAR 

Breakfast {seven to eight a. m.) : Cereals, as oatmeal, hominy, 
cornmeal, cracked wheat, macaroni or rice, well cooked and served 
w T ith cream and sugar. Eggs in some form, with the exception of 
fried. Bread spread with little butter, or toast, or Graham crack- 
ers. One to two glasses of certified milk. Avoid hot bread, rolls 
or biscuit, griddle cakes, and tea or coffee. 

Dinner {twelve to one p. m.) : Broth or soup. Meat — preferably 
steak, chops, rare beef, lamb, or chicken. Eresh fish, boiled, broiled 
or baked. Vegetables — Potatoes once daily with cream, or beef 
ju^ce, spinach, asparagus, green peas, string beans, stewed celery, 
squash, and new beets. For dessert — baked apples, orange, stewed 
prunes; rice, sago and tapioca pudding, bread pudding without 
raisins, soft custard, junket, and ice cream occasionally. Also stewed 
pears and peaches, if soft, and ripe grapes, if seeds are removed. 

Forbid : ham, sausage, or pork of any kind ; also corned beef, 
game, duck, liver, stews, rich gravies, dressing for roast meat, salt 



264 FOOD FOR INFANTS AND THE SICK 

and smoked fish, and fish balls. Cucumbers, green corn, cabbage, 
cauliflower, sprouts, baked beans, old beets and carrots, raw celery, 
onions, fried potatoes, egg plant, and tomatoes; also tea and coffee. 

Supper (six p. m.) : Cereal or bread and crackers, and twelve 
ounces of milk. 

Give plenty of water between meals. 

Forbid: candy, nuts, cake, pie, tarts, pastry, tea and coffee at 
all times, and eating of any sort between meals — a most common 
and harmful habit. Enforce regularity at meals, the taking of 
plenty of time, and slow eating of food. 

To avoid peculiar tastes as regards food, require that simple 
food be eaten, even if at first distasteful, and allow the food desired 
only after the child has eaten the distasteful article. 



PART II 

CHAPTER I 
PEKSONAL HYGIENE 

Baths : cold, outdoor, tepid, warm, hot, and Turkish. Care of the complexion, 
hair, and nails. Choice of clothing. 

BATHS 

Baths are useful for various purposes. Cleanliness demands that 
the ordinary person should bathe at least twice a week. Dead, scaly 
particles and fatty secretions of the skin, dirt, and sweat — interfering 
with the proper functions of the skin in eliminating waste matters 
— are thus removed, and the kidneys are relieved of performing 
extra work in carrying off waste matters from the blood, which is 
forced upon them when the pores of the skin are clogged and irritated 
by dirt. 

Clogged pores lead to skin eruptions, as the common pimples or 
acne of the young. The daily cold bath (temperature 40° to 70° F.) 
has a powerful stimulating action on the circulation and nervous 
system, in addition to its cleansing functions. How great this is 
may be realized when one appreciates that dashing cold water on 
the chest has often more effect in restoring consciousness — by ex- 
citing the action of the heart and muscles of breathing — than any 
other remedy. 

Cold Baths. — The cold bath habit is common among the better 
classes in England and America, and ruddiness, fine complexions, 
and robustness, are in no small measure due to the custom. A 
daily cold bath should be taken on rising by every one under middle 

265 



266 PEESONAL HYGIENE 

age having the facilities and able to secure the afterglow or reaction 
which should always follow if the bath agrees. If the bathroom is 
very warm, reaction is much more apt to occur, and failure in secur- 
ing a good reaction is often due to a cold bathroom in winter. The 
cold shower, or merely sponging the body with cold water from a 
basin, may be used as substitutes. 

For many persons unable to take a cold bath without feeling 
chilly afterwards, and for children, the use of hot water to sit or 
stand in while taking a cold shower or sponging, will often give the 
best results. Persons unaccustomed to cold baths should begin them 
in summer and they will thus be able to continue them through the 
winter with ease. They are valuable for many who think them im- 
possible; namely, those who take cold readily and frequently, and 
those below par and needing nervous tone. The cold water should 
be applied to the skin but a minute or two, and brisk rubbing with 
a coarse towel should follow. 

For young children, old persons unaccustomed to cold water, all 
persons with weak hearts and high blood pressure, and for women 
who are menstruating or in the later months of pregnancy, cold 
baths are inadvisable. Also they are harmful to persons fatigued 
by severe muscular exertion and to those excessively hot, but may 
be taken by healthy persons warm with moderate exercise. 

Cold baths should be taken before breakfast or, at other times, at 
least three hours after eating. 

Outdoor Bathing. — The pure air, the exercise, the sunlight, the 
stimulating effect of the waves and salt (in sea water), and in addi- 
tion, the pleasure, make this form of cold bath (usually from 60° 
to 75° P.) particularly health-giving. It is often, however, grossly 
abused. The effect of remaining in cold water for a considerable 
time causes an immense loss of body heat and consequent drain 
upon the vitality. This is shown by the tremendous fall of tempera- 
ture seen in patients treated by cold baths for fevers and sunstroke, 
in which the patients remain no longer and with water no colder 
than in sea baths taken for pleasure. 

Sea bathing is indeed notoriously exhausting to those who stay 
in the water too long, particularly in the case of children who have 



BATHS 267 

the pernicious habit of alternately playing out of the water in wet 
bathing suits (evaporation from which is constantly cooling them) 
and again returning into the water, or wading with bare feet in 
cold water while their bare heads are exposed to the burning sun 
— a combination most favorable for sunstroke. 

Fat persons can stay in cold water for some time without ill 
effect; in fact, long distance swimmers have to be covered with 
considerable adipose tissue to withstand the cold. The length of 
stay in the water depends wholly upon its temperature — anywhere 
from two to twenty minutes. The former is too long in many parts 
of the northern New England and Pacific coasts, whereas the latter 
is only too short in many of the shallow waters of Cape Cod and 
middle and southern Atlantic coast of the United States where the 
water is often 72° to 75° F. or higher. 

The stay should never be so long as to cause blueness of the lips 
and fingers, chattering teeth, or chilliness later. The head should 
always be wet before plunging into cold water, either by dipping the 
head or diving. It is unwise to enter cold water when excessively 
hot, but it is safer to bathe when moderately warm than when 
beginning to cool after exercise. Those accustomed to cold water 
may bathe before breakfast to advantage; others should wait until 
three hours after this meal, or for the same period after other meals. 

Immersing the whole body in cold water at first drives the blood 
from the skin to the internal organs and to the head, if it is not 
wet, and disturbs the even distribution of the blood about the body. 
After eating more blood collects in the stomach than usual and 
agencies still further altering the distribution of blood — as bathing 
in cold water — may work harm. Nausea, vomiting, cramps in the 
bowels and sudden deaths have occurred in bathers who have en- 
tered cold water soon after eating. 

Sudden and unexpected deaths among bathers and swimmers are 
frequently due to either special weakness of the heart or over- 
exertion. 

The dangers of muscular cramps are probably magnified. There 
is no more violent exertion than rapid swimming in rough water, and 
great strain is wrought on even the healthy heart, particularly in 



268 PERSONAL HYGIENE 

those who are not in training. Then again the nervous shock of 
a sudden plunge into cold water is sufficient to stop the action of a 
weak heart and result in temporary unconsciousness and drowning 
unless help is at hand. 

Those who are subject to fainting, palpitation, or known dis- 
turbance of the heart, and the elderly not habituated to cold water, 
should refrain from bathing outdoors, and also those who are likely 
to suffer from cold baths, as noted above. * 

The Tepid or Lukewarm Bath (80° to 90° F.).— The tepid or 
lukewarm bath has no special effect on the body apart from the cleans- 
ing action. It is suitable for the elderly, convalescents, and those 
who do not react well to cold baths. It may be taken at any time 
of day but preferably not directly after meals. 

The Warm Bath (100° F.). — The warm bath is useful in aiding 
sleep when taken before bedtime, and also in hardening of the ar- 
teries and in Bright's disease of the kidneys, when the patient may 
remain submerged for five minutes once or twice daily. 

The Hot Bath (105° to 110° F.).— The hot bath is unsuitable 
except for the strong, as it is depressing to the circulation, and 
fainting may ensue. It should only be used at night, or when the 
bather is to stay in a warm atmosphere, and not after meals. At 
bedtime the hot bath may, however, cause sleeplessness, unless a 
cold cloth is kept on the head during the bath. The hot bath is very 
valuable in preventing colds after exposure and chilling, to relieve 
pain, as in colic due to the passage of a stone, to stop convulsions 
in children, and to produce sweating in many disorders, as described 
in other sections of this book. 

The Turkish Bath. — This consists of a hot air-bath (120° to 
170° F.) for ten to thirty minutes, followed by a hot shower-bath, 
then shampooing and general massage in warm moist air (100° to 
110° F.), and finally by a warm shower-bath changing to cold, with 
thorough rubbing and drying followed by rest for half an hour in 
blankets. 

Turkish and Russian baths are unsafe for persons having weak 
hearts or for those who are very stout. They are of value in the 
first stage of a cold, but the patient must go home in a covered 



THE COMPLEXION 269 

i 

vehicle and go to bed, for exposure to cold may bring on bronchitis 
or other respiratory trouble. 

Muscular or joint stiffness, following severe physical exertion, 
and some forms of rheumatism, are much benefited by the Turkish 
bath. 

THE COMPLEXION 

Cold water is better than warm for the complexion and for 
the skin of all parts of the body. It improves the tone of the skin 
of the face, gives color, and prevents wrinkles. Chapping of the 
skin is more apt to follow the use of hot water. 

The countless toilet preparations made for application to the 
face may afford some pleasure to the users, but a few simple reme- 
dies will suffice. Rice powder may be applied to the face in warm 
weather, and cold cream, or equal parts of glycerin and rose water, 
in cold weather, when the skin is dry and rough. The various face 
or toilet creams in the market are usually harmless, and are of 
service in chapping. The face powders are also generally innocuous, 
but are more expensive than rice powder. 

The habitual use of soap on the face is not advisable except in 
the case of an oily or soiled skin. Thus in acne, or pimples on the 
face the skin may be scrubbed once daily with the tincture of green 
soap and the lather left on to dry. This will irritate the skin after 
a few days, so that it will become swollen and scaly, when cold 
cream may be applied. 

At the same time one should practice massage of the face, with 
cold cream on the finger tips, so that the skin on the forehead is 
stroked out from the middle toward the temples and that of the 
nose stroked downward, while the cheeks are rolled between the 
fingers and thumbs. This treatment tends to empty out the secretions 
in the pimples. 

There is a vast deal of nonsense in the popular idea that great 
care must be exercised in the selection of a toilet soap. One toilet 
soap is about as good as another so far as any beneficial or injurious 
action of either on the skin is concerned. Soaps are made from 



270 PERSONAL HYGIENE 

various kinds of fats boiled with an alkali. The cheaper grades of 
soaps, as the yellow laundry variety, contain an excess of alkali 
and are therefore more useful in removing grease from clothing but 
are harmful in causing roughness and drying of the skin for the 
same reason. 

The more expensive soaps have little or no free alkali and one 
is about as serviceable as another. Plain Castile soap is the simplest 
of these. Medicated soaps have no great value since the drug in 
them comes in contact with the skin for so short a time. 



THE HAIR 

Baldness. — Baldness is caused by a disease, the commonest symp- 
tom of which is dandruff. Baldness is favored by wearing close- 
fitting, ill-ventilated hats, and by deficient blood supply to the hair 
resulting from a tight-fitting scalp. The best mode of treating bald- 
ness is by shampooing and brushing, as described in detail under 
Baldness and Dandruff (Part I, Chap. IX I. Most pomades and 
hair tonics are of no value. Cutting does not increase the number 
of hairs, although it makes the hair grow faster. 

Barbers are prone to advise singeing to stimulate the growth 
of hair, but this is of no worth (except to the barber I, as it has no 
effect on promoting the growth of hair. Constant wetting of the 
hair, practiced by some young persons, is harmful. 

Skin Diseases. — Several skin diseases caused by parasites are 
not infrequently conveyed by barbers to their customers by means 
of razor, scissors, their hands, and especially by moist towels. Among 
these are ringworm, barber's itch, boils, and even carbuncles. The 
only way to avoid such accidents with certainty is for the patron to 
furnish his own razor, scissors, brush, comb, shaving soap, cup and 
brush, or see to it that the barber cleans his own scissors or razor 
with alcohol (two parts) and water (one part), and uses a clean, 
dry towel. 



CLOTHING 271 

FINGER AND TOE NAILS 

The finger nails should be trimmed so as to follow in outline the 
contour of the finger tips ; the toe nails should be cut in a straight 
line directly across to avoid pressure by the toes of the boots. 

CLOTHING 

Underclothing*. — In regard to underclothes there are two factors 
of importance. First, the property of retaining the body heat. Of 
the three fabrics most frequently used for clothing, wool is the 
greatest non-conductor, and therefore retains heat most effectually. 
Impervious materials, as rubber, leather, and mackintosh, retain heat 
but are unsuitable (because affording poor ventilation), except for 
outer clothes, as protection from the wind and wet, when one is not 
taking sufficient exercise to cause much perspiration. 

Second, the power of absorbing moisture. Wool possesses the 
power of rapid and free absorption, but gives out the moisture slowly. 
Cotton, on the other hand, does not absorb moisture so readily and 
cools the body much more when wet. Linen is about on a par with 
cotton as regards absorption of moisture and retention of body heat. 
Wool is thus the best material for underclothing, but is so irri- 
tating to the skin that some persons can not tolerate it. To overcome 
this merino, or mixtures of cotton and wool, may be worn. In some 
clothing there is a layer of wool and cotton, the latter next the skin. 

As the property of retaining body heat, residing in wool and 
fur, is largely due to air spaces in these materials, it is found that 
cotton fabrics woven loosely will, to a considerable degree, take 
the place of wool. Wool shrinks and becomes matted like felt by 
continuous washing. Washing in tepid water with frequent rinsing, 
but without much wringing or rubbing, will in a large measure 
prevent this felting of woolen goods. 

Woolen underclothes are desirable the year round for those who 
perspire freely, and in certain diseases, as so-called chronic rheuma- 
tism and Bright' s disease. Linen garments are much more expensive 
than cotton but will endure more washing. The linen mesh makes 



872 :z: -: val hygiene 

an excellent fabric for hot weather and the :ropics, as it imparts a 

sense of coolness not felt in cotton. Undergarments of bright hoes 
and colored stockings are most undesirable, since the airilrn colors 
used often irritate the skin and produce eruptions. 

Stockings should be changed frequently, especially if the feet 
perspire freely. If this occurs, the feet should be soaked in hot 
water, dried, and dusted with a mixture of salicylic acid (1 part) 
and starch (3 parts). The same treatment is useful in excessive 
perspiration of the hands, and will tend to remove unpleasant odor. 

Dampness of the underclothes from perspiration fakirs the 





A B 

--- n __£ Pbqfeb Shah :? Sou :? Shoe. B. Fi^t Bom n Peofile or a 8ho«. 

growth of disease germs and skin parasites, so that clothes should 
either be changed when wet or well aired and dried, when removed. 

Outer Clothing. — In regard to the outer clothes, black or dark 
shades absorb heat rays of the sun more than white fabrics, so that 
white is worn in the tropics and in hot weather. 

The amount of slothing worn should depend upon the tempera- 
ture. While heavy underclothing is needful for those living out- 
doors in cold weather it is unwise for those spending most of their 
time indoors in a summer temperature, and many people acquire 
colds by so doing. The proper way is to foesa much as in summer, 
while in the house in cold weather, but warmly with ulsters, furs, 

. before going into the cold. 

Footgear. — Hats should not fit but shoes should. A hat made to 
tit the head is undesirable, in obstructing the circulation and in pre- 
venting ventilation. A s::e should be made to conform to the out- 



CLOTHING 273 

line drawn from the stockinged foot. Shoes should be three-quar- 
ters of an inch longer than the foot, the inner line of the toe and 
heel should practically form a straight line. 

The toe should neither be pointed nor absolutely square and the 
sole should be nearly absolutely flat on the bottom and not turned 
up at the toe from the ground, like the section of a rocker. The 
heels should be low. The extension of the soles outward around the 
uppers affords better support for the foot and pleases some people. 

In the cut (Fig. 46) is shown the proper shape of the sole of 
a shoe and also the flat sole in the profile of a shoe. 



CHAPTEE II 
PEESOXAL HYGIEXE (Continued) 

Hygiene of the digestion. Care of the teeth. Eiggs' disease. Constituents 
of food — including meats, fish, shellfish, eggs, milk, vegetables, cereals, 
bread, fruits, salts, and water — and their values as articles of diet. The 
function of cooking. Tea and coffee. Alcohol. Tobacco. 

HYGIENE OF THE DIGESTION 

Digestion should begin in the mouth. The food should be chewed 
thoroughly, not only because when finely divided it is more readily 
mixed with the digestive juices of the stomach and bowels, but be- 
cause it is in this way more fully combined with the saliva which 
aids the digestion of cooked starchy elements of the food. 

It has always been known that hasty eating favors dyspepsia, 
but it is the x-ray which explains the fact. Eapid eating causes 
too rapid distention of the stomach with food and swallowed air, and 
this is what causes pain. 

In order that food shall be properly chewed the teeth must be 
good. Decay or loss of the teeth are commonly regarded as fre- 
quent causes of indigestion. It is now recognized that many severe 
and remote diseases are produced by decay of the teeth and inflam- 
mation of the gums and mouth, so that there is a vital reason for 
keeping the teeth and mouth in good condition. Decay of the teeth 
is brought about through the agency of germs. A very frequent 
disease of the gums is the so-called Eiggs' disease. 

An improper mode of life is probably more often the cause of 
indigestion than any other disorder. But the great causes of func- 
tional dyspepsia are nervous debility and faulty build, described in 

274 



HYGIENE OF THE DIGESTION 275 

detail elsewhere. In patients with nervous weakness any cause 
which leads the patient to become "run down" will induce indigestion, 
so that calamities, acute diseases, operations, overfatigue, sexual 
excesses, or lack of sleep are common factors. Excessive quantities 
of food or water are bad in dilating the stomach and giving rise 
to lack of tone so that the contents lie in the stomach for hours un- 
digested and give rise to distress. 

The popular fad of cold water drinking may thus induce indi- 
gestion. Hasty eating, eating alone, worry, or anything which dis- 
turbs the equanimity of mind either during, before, or after meals, 
unpalatable or improperly cooked food, abuse of alcohol, tea, or 
coffee, pastry, fried food, candy in excess, lack of exercise, faulty 
mode of dress in women, overwork or want of occupation, irregu- 
larity in the hours of eatings — all favor dyspepsia. 

Many diseases remote from the stomach give rise to disturbances 
of digestion — in fact, as we have pointed out elsewhere, ninety per 
cent, of so-called stomach trouble originates in disease elsewhere. 
Among these are especially abdominal disorders, as chronic appendi- 
citis, and gall-stones, consumption, Bright's disease, eye strain, 
anemia, nervous prostration, etc. 

Recent research has shown that secretion of the digestive juices 
in the stomach is started by the desire, sight, and smell of palatable 
food. It has been found that simply displaying meat to a dog will 
cause the gastric juices to flow. Then it is known that the later 
secretion in the stomach and bowels is dependent on the stimulation 
of that first secreted, so it will be seen what a power desire for 
food has upon the gastric digestion, and indirectly all the later diges- 
tion in the stomach and intestines. 

The wonderful progress which has enabled us to actually see all 
the movements of the stomach by means of the x-ray, when some 
form of metallic powder has been swallowed which coats the organ 
(bismuth, barium), has greatly increased our knowledge of digestion. 
Hunger appears to be due to very strong contractions of the stomach 
which are lessened by the secretion of gastric juice, food, and warm 
water. When the food reaches the stomach wave-like contractions, 
starting every ten to twenty seconds, serve to mix the food and 



276 PERSONAL HYGIENE 

force it, a little at a time, onward into the bowel, where the most 
important part of digestion occurs. 

The digestion of starch, started by the saliva, continues for a time 
in the stomach until the acid gastric juice stops the action of the 
alkaline saliva. The acid food-product of the stomach (chyme) is 
emitted in jets into the small intestine by an ingenious mechanism 
whereby the effect of the acid on striking the coat of the intestine 
causes the outlet of the stomach (pylorus) to close and, as soon as 
the acid is neutralized by the alkaline juices in the bowel, the out- 
let relaxes and allows another escape of acid food-product (chyme) 
from, the stomach — and so the outlet of the stomach opens and 
closes automatically until the organ is emptied. 

Very hot and very cold food lessen the activity and digestive 
power of the juices, and if the food is not well chewed the lumps 
irritate the stomach and the juices act imperfectly on the surface 
of the food. 

Much the same result occurs in the case of food which is fried 
or sauted. Frying or more properly sauteing, for a long time — in a 
frying pan — causes the food to become hard and tough and to be 
saturated with grease, so that the gastric juice has somewhat the 
same effect upon such food as water upon a well-greased boot. The 
proper method of frying consists in immersing the food in boiling 
fat in a kettle. The temperature is so high (400° F., or twice that 
of boiling water) that the fat immediately hardens the surface of 
the article, and this — together with the steam from the moisture 
inside the food — tends to keep the fat from entering and saturat- 
ing it. 

Into the bowel— and but a few inches from the outlet of the 
stomach — enter through a common duct the secretions of the liver 
and pancreas (bile and pancreatic juice), and these, together with 
a very important secretion from the walls of the intestines, com- 
plete the digestion. Intestinal digestion is much more important 
than that occurring in the stomach, as is shown by compara- 
tive health enjoyed by persons from whom a large part of the organ 
is removed for cancer. Also, while only cooked starchy food is par- 
tially digested by saliva, and only proteids (see below) are partially 



HYGIENE OF THE DIGESTION 277 

digested in the stomach, the intestinal juices are capable of digest- 
ing all three nutrients — fats, starches, and proteids. 

By digestion is meant a change brought about by mechanical, 
vital and chemical actions, whereby the food is disintegrated and 
rendered fluid, and the insoluble part so altered in chemical nature 
as to become soluble and capable of being absorbed into the vessels 
from the walls of the intestines. A food is as much outside the 
body when it is in the stomach or bowels, as it would be on the 
skin — so far as its having any nutritive value — unless it is so di- 
gested as to be absorbed into the blood and assimilated by the cells 
of the body to build tissue or give rise to heat or muscular work. 

Cooking has of course an immense influence on the digestibility 
of food. For reasons stated above broiling is better than frying, 
and baking is better than boiling or stewing. Foods impregnated 
with fat are indigestible, and that is why pastry is unwholesome, 
although made out of the most wholesome materials. 

In baking, broiling, or frying meat or fish a high temperature 
should at first be applied, to form a firm coating which retains the 
flavor and juices, while a more moderate heat is then used to con- 
tinue the cooking. In making soups the opposite course should be 
pursued, the meat being cut up and allowed to stand in cold or mod- 
erately heated water (simmering) for several hours to extract the 
juices. Stews are made by placing the meat in enough cold water 
to cover, cooking very slowly till the boiling point is reached, and 
then allowing cooking to proceed at the simmering point until the 
meat is tender. 

The custom, which is becoming more general, of deferring the 
most substantial meal to the later hours of the day is based on the 
theory that there is greater leisure and freedom from mental and 
physical activity at this time. This state favors digestion, as muscu- 
lar or mental work draws blood away from the digestive organs to 
the muscles or brain. 

The case of children is different; it is better for them to have 
the principal meals at breakfast and midday, and a light meal before 
retiring. It is also very important to prevent children from eating 
between meals, especially candy, bizarre soda water concoctions, 



278 PERSONAL HYGIENE 

ices, and sweets. This is a common cause of poor health in boys 
and girls and the plain diet and avoidance of such indiscretions, 
required by some boarding schools, has a remarkable effect at times 
on children from the best ( ?) homes. Persons doing heavy manual 
labor usually have large appetites and good digestive powers, and 
so require and take large amounts of food at each meal with im- 
punity. 

The matter of dress in women affects the digestion. The use of 
corsets constricting the upper abdomen displaces downward the stom- 
ach, liver and intestines, and causes kinks to form in the intestines 
which lead to constipation and indigestion (See Enteroptosis). The 
modern corset goes to the other extreme and embraces the lower 
abdomen and thighs. Some of the straight front corsets may be of 
much value in supporting the lower abdomen. 

CARE OF THE TEETH 

This applies not only to the prevention of decay of the teeth, 
but of irregularities and deformities of the jaw. The narrow upper 
jaw with the high Gothic roof of the mouth is usually the result of 
adenoids and tonsils. Because the tendency of civilized life is 
toward the use of soft prepared foods, the muscles and jaws are un- 
developed and are too small for the teeth which take up irregular 
and crowded positions. This again leads to deformities of the 
jaws and aids decay by providing crevices for the lodging of food. 
Loss of the first teeth too early or late also favors deformities of 
the jaw. There may be protrusion of either the lower or upper 
jaw. The latter is induced by the sucking of the thumb in infants 
which throws the front teeth forward. 

The presence of supernumerary teeth is another cause of deformi- 
ties. Deformities appear between the ages of seven and fourteen, 
when they can frequently be corrected by dentists, as in caring for 
the first teeth or by straightening the teeth, or orthodontia, which 
has reached such a state of perfection in the last few years. By this 
method the whole future shape of the jaw may be greatly improved, 
and decay prevented by doing away with irregularities which harbor 
food and germs. 



HYGIENE OF THE DIGESTION 279 

Adenoids and tonsils should be early removed to prevent alter- 
ation in the shape of the mouth. 

The greatest single aid to cleanliness of the teeth is a perfect 
polish and the removal of all roughness and irregularities. To this 
end the teeth should be put in such a condition by the dentist and 
should be kept so by removal of tartar as it collects, and by monthly 
visits to him thereafter for preventive treatment and polishing. 
The teeth should (ideally) be cleaned after each meal, but certainly 
once daily before retiring at night. Food may lie on the teeth longer 
at night than at any other time. 

The toothbrush should be small and of bristles of varying length 
so as to reach into the irregular depressions, and not stiff enough to 
cause the gums to bleed. One should not use the toothbrush as a 
scrubbing brush, but more as a clothes brush to brush food out of the 
various crevices on the grinding surfaces and from the spaces be- 
tween the teeth. A tooth powder or paste should be employed con- 
taining some mild antiseptic, as boric acid or oil of wintergreen. 
It stimulates the flow of saliva — which counteracts acidity and 
washes the teeth. 

RIGGS' DISEASE 

{Pyorrhea alveolaris) 

Symptoms. — This is an inflammation beginning at the edge of 
the gums, where they join the neck of the teeth, so that the gums 
become tender, swollen, and deeper red, and shrink away from the 
teeth in time while the latter become loosened, and feel tender and 
elongated. Pus or matter may often be squeezed out about the 
teeth by pressure on the gums. 

There is a bad taste and the breath is unpleasant. It is a uni- 
versal disease, at some time during every one's lifetime, half of 
the permanent teeth are lost through this means. The process is 
usually slow of onset, the pain is slight, and patients who are not 
careful often wait until the teeth loosen before applying for treat- 
ment. The trouble begins in the back teeth, and the first sign may 
be the bleeding of the gums. 



280 PERSONAL HYGIENE 

In the less common acute cases there is considerable pain, and 
the gums and teeth are so tender that the patient cannot eat hard 
food or use a tooth brush. 

Cause. — The true cause of Biggs' disease is thought to be due to 
a microscopic animal organism ( Entameba ■ , allied to the germs 
causing malaria and amebic dysentery. Such germs commonly exist 
in the mouth, but only attack the tissues when these are injured, or 
the general tone is lowered by disease. 

The injury is usually produced by the accumulation of tartar 
on the neck of the teeth, by irritation of toothpicks, by food jammed 
between the teeth, or by ill-fitting crowns and bridges and over-hot 
food. General disease, as gout, diabetes, debility, special infections, 
and mercury poisoning (salivation ) reduce the vitality of the gums 
and render them more susceptible to inflammation. 

The primary and essential cause of Riggs' disease is local irrita- 
tion. The immediate cause is the growth of germs — possibly the 
entamebae, and certainly pus genus which attack the gums and pro- 
duce inflammation of the membrane (peridental ) covering the roots 
of the teeth and also lining their sockets. 

This leads to the formation of matter or pus in which these germs 
flourish, the root of the tooth and the bone of the socket are thus 
laid bare through destruction of the normal covering membrane. 
A pocket containing pus, between the root of the tooth and its socket, 
is the result. This grows deeper and deeper as the months pass, 
the teeth loosen, and finally drop out. 

Cure. — There are some fifteen varieties of germs in the mouth, 
besides those directly causing Riggs' disease. One of the great dis- 
coveries of recent years is the fact that such serious diseases as 
chronic rheumatism, valvular heart disease, chronic Blight's disease, 
and apparently gall-bladder trouble and chronic appendicitis, origi- 
nate through the entrance of germs into the blood from inflammation 
of the gunis. Hence the cure of such a condition is of the most 
vital importance. 

The cure of Riggs 3 disease depends both upon the discovery of its 
cause and the fact that ipecac is the special poison for the entamebae. 
as in the case of dvsenterv. 



CONSTITUENTS OF FOOD AND THEIR VALUE 281 

Bass and Johns find that brushing and rinsing the teeth thor- 
oughly twice daily with a solution containing two drops of fluid- 
extract of ipecac in a half glass of water kills the special germs 
superficially exposed. To kill those deep in the tooth sockets the 
same drug is given by the mouth and acts through the blood. Once 
a month, until the disease is cured, two Alcresta ipecac tablets should 
be taken thrice daily for six consecutive days. They are harmless, 
but may cause some abdominal discomfort and looseness of the 
bowels. The mouth wash should be used indefinitely, as weeks or 
months are required for the pockets to heal about the teeth. It is 
more essential for a dentist to treat the teeth locally by destroying 
the pus pockets, and to keep the teeth scrupulously clean and free 
from tartar. It is much easier to prevent than to cure Riggs' disease. 
Monthly visits to the dentist, to prevent sources of local irritation, 
will avert the disorder. 



CONSTITUENTS OF FOOD AND THEIR VALUE 

The essential elements of food comprise proteids, carbohydrates, 
fats, salts, and water. Any food or combination of foods containing 
all of these in right proportion may be regarded as complete; that 
is, a complete food is one which would alone support an individual 
indefinitely. Milk comes nearest to such requirements in a single 
food. Cream contains most of the fat; the casein is the chief 
constituent of curd (in sour skim milk) and is a proteid, while sugar 
of milk, dissolved in the water, is a carbohydrate. 

Proteids form a large part of the nutritive matter in meat, 
fish, eggs, and in certain vegetables, as cereals (especially oatmeal), 
and peas and beans. The value of proteids lies in building up 
tissue, which is constantly consumed in the vital processes, and in 
forming new tissue in the growing individual. Proteids also yield 
heat and energy by their destruction in the body — but this is the 
role played chiefly by the carbohydrates — and they may also form fat 
in the body. 

Proteids are generally the most expensive food, especially in the 



282 PERSONAL HYGIENE 

very digestible and concentrated form in which they exist in animal 
products, as meat, fish, eggs, and milk. 

The animal foods represent the essence of nutriment which has 
been extracted from vegetables. Lean meat contains seventy-five 
per cent, of water, but the rest is practically all protein. Beef con- 
tains the most nutritive matter but its fiber is supposed to be a 
little coarser and less digestible than mutton or lamb. The strong 
flavor of mutton renders it unpalatable as a constant diet. Both 
pale and very dark beef are undesirable; the former is not suffi- 
ciently hung; the latter has not been properly bled, or is diseased. 
Beef well streaked with fat is juicier and more palatable although 
containing much less water (fifty-five per cent.) than lean beef. 
Yeal is as digestible although slightly less nutritious than beef, lamb, 
or mutton. If pale and soft it is too young (under a month), if 
only pale the animal was probably bled to death. 

A marked distinction between light and dark meats has been 
made by physicians in the past. Light meats (as chicken) have 
been allowed in gout, rheumatism, etc., while dark meats have been 
forbidden. As a matter of fact the chemical composition of both 
is so nearly alike as to be identical. 

There are certain bodies called purins which give rise to uric 
acid in the body. Uric acid is not readily eliminated in gout, and 
its retention poisons the patient and gives rise to the symptoms of 
the disease. The purin bodies are derived from the nucleus of animal 
cells chiefly, and such animal foods as sweetbread, liver, kidney, 
brain, fish roe, caviar, meat extracts and bouillons, are particularly 
rich in them. All the meats contain a considerable amount of purin 
bodies, but beefsteak almost twice as much as other parts of the 
animal. There is not much difference in the amount of purin bodies 
contained in light and dark meat, however. 

But vegetables are not by any means free from purins ; they are 
found in the nuclei of all seeds. Dried peas and beans are especially 
rich in purins and are nearly on a par with meat in this respect 
and in the amount of protein they contain. Yet, as a whole, vege- 
tables are comparatively poor in protein and purins, and fresh 
vegetables contain a relatively small amount of either since they 



CONSTITUENTS OF FOOD AND THEIR VALUE 283 

are composed chiefly of water. Milk, cream, eggs, cheese, fresh 
vegetables, and fruit, are practically free from purin bodies and 
form the suitable diet for those with gout, and hardening of the 
arteries. 

There are also certain so-called extractive matters in meat, such 
as exist in meat extracts, beef tea, and clear soup. They are useful 
as stimulants in sickness when much nourishment is impossible; 
they stimulate the appetite but possess slight food value. Fish is 
wanting in these stimulating bodies, but in the matter of compo- 
sition differs little from meat in the amount of protein and purins 
it contains. In lacking these stimulating extractives it may have 
some advantage over meat in certain disorders, as hardening of the 
arteries. There is a distinct difference, however, between the digesti- 
bility of light and dark meat of fish, the dark meat being much less 
digestible (as salmon, mackerel) in certain conditions owing to the 
greater amount of fat it contains. The eating of fish for its tonic 
effects on the nervous system, owing to the appreciable quantity of 
phosphorus it contains, is an exploded idea. 

Shellfish, as crabs and lobsters, are occasionally poisonous to 
some people, causing digestive disturbances and nettlerash or other 
eruptions. They should be eaten within twenty-four hours from the 
time they are killed by cooking. Clams and oysters should also be 
eaten as soon as killed. The latter have frequently been a cause 
of typhoid fever when growing in water polluted by sewage con- 
taminated with these germs. 

Pork contains much nutriment, especially in the form of fat, 
but is difficult of digestion, and is more suitable for those living 
outdoors. Unless thoroughly cooked it may communicate parasites 
— trichinae and tapeworm — to man. 

In regard to the relative food value of meat it may be said that 
it is the most concentrated form of digestible diet (including eggs), 
and is stimulating to the nervous system. It is possible to live on 
fat meat and water alone, as the meat contains a small amount of 
carbohydrate (muscle sugar). One of the most finely developed 
tribes in Eastern Africa, the Masai, live almost wholly on blood 
and milk, rarely taking solid food. 



284 PERSONAL HYGIENE 

The amount of meat advisable for daily consumption depends 
upon age, occupation, and climate. Young and growing individuals, 
those doing strenuous mental and physical work, and those doing out- 
door work — especially in cold weather — need an abundant supply of 
meat, fish, or eggs. For most persons leading a quiet, sedentary ex- 
istence such a diet is not necessary, and may be harmful. 

As meat is the most expensive article of diet and the most 
palatable it is apt to be eaten in excess by the well-to-do. In this 
event the products formed in the body are not sufficiently consumed 
and the waste, accumulating in the system occasions such diseases 
as gout, stone, arteriosclerosis, and possibly various nervous dis- 
turbances. In some disorders, as Bright's disease, meat may be 
positively fatal. 

Notwithstanding the present medical consensus of opinion that 
an excessive meat diet favors arteriosclerosis there are vegeta- 
rian monks and natives of Oriental and tropical countries who 
develop the most marked types of this disease on a wholly vegetarian 
regimen. 

In eggs we also have a concentrated food. The white of the egg 
is practically pure protein, with water and salts. When firmly 
coagulated in hard-boiled eggs it is not nearly so digestible as when 
raw. coddled, or soft boiled. In the yolk of the egg there is much 
fat (thirty per cent. | and some protein. For this reason if eggs 
are eaten too constantly their fat may produce so-called biliousness 
in persons who have weak digestion. 

The amount of fat in the yolk of eggs may therefore create a 
distaste for eggs altogether, so that in giving eggs to the sick in 
milk it is well to only use the raw whites, which are also commonly 
given dissolved in cold water. 

Milk is more particularly useful in supplying protein and fat. 
Its composition .and method of feeding it to babies is described 
elsewhere. For the sick as well as for infants milk should be pas- 
teurized, since bacterial contamination is most apt to hurt those in 
a delicate state of health and, especially, when milk constitutes their 
chief diet. Milk becomes curdled or partially solid through the 
action of the acid in the stomach, so that it should be regarded as 



CONSTITUENTS OF FOOD AND THEIR VALUE 285 

a solid food. When digestion is very feeble fluids, like broths and 
white of egg and water, or beef juice, are more appropriate. 

Milk to which is added salt, or one-third lime water, or rich milk 
diluted with an equal amount of carbonated water is more digestible. 
A preparation called liquenzyme aids in the digestion of milk, and 
one teaspoonful may be added to a glass in case milk does not agree. 
It is well not to take milk cold from the ice but slightly warmed, 
unless mixed with soda water. 

Milk is the most valuable food for the sick, but it takes at least 
two quarts of milk to support a person in bed. The food value of 
one glass of milk is equal to that of two large eggs, two potatoes, 
two slices of bread and a large serving of lean meat (Rosenau). 
If half milk and half cream are taken much less is necessary. Milk 
is more readily digested if taken with crackers or toast, or some 
starchy food, and is more appropriate at the lighter meals, or between 
meals, or at bedtime, than at dinner. 

The author is accustomed to recommend to the thin and debili- 
tated one pint each of milk and rich cream (mixed) daily, one 
glass at breakfast, one in the middle of the morning, one at lunch, 
and one at bedtime. It is not unusual to see a gain of twenty 
pounds in three months on this diet. 

Vegetables also contain the same chemical constituents as meat. 
To obtain the same amount of protein, as in meat, a much greater 
bulk would have to be eaten, and vegetables are not so digestible as 
meat. Peas and beans in the dried state contain about as much 
proteid as meat (twenty-five per cent.), however, and nearly fifty 
per cent, of starch, and are therefore extremely nutritious when they 
are well digested. This accounts for the popularity of baked beans 
which, with the fat derived from pork, form a very complete food 
for outdoor workers. Pea and bean soups are both digestible, cheap, 
and exceedingly nutritious. 

All cereals contain considerable proteid matter — ten to twenty 
per cent. — of which wheat is the most valuable, but as carbohydrates 
(or starches and sugars) are the chief nutrients we will consider them 
under this head. Rice contains little but starch. The carbohydrates 
then predominate in vegetables, although protein and a not incon- 



286 PERSONAL HYGIENE 

siderable amount of fat may also be present. The product of the di- 
gested starches and sugars is sugar which is burned in the liver and 
muscles to form heat and energy in the body. 

The carbohydrates furnish the fuel for the bodily machine, 
while the proteids build the machine and keep it in repair by sup- 
plying new substance to the tissues as they waste in the wear and 
tear of life. 

Carbohydrates may also form fat and, in being more readily 
consumed in the body, protect the more valuable proteids from 
consumption. 

There is not enough protein in vegetables to form a complete 
food without the addition of abundant fat. Thus bread and butter 
make a pretty complete food, but the amount of protein is too small 
and the bulk too great to form a suitable diet. Fat is consumed 
in the body with the liberation of heat and energy, but an equal 
weight is approximately twice' as valuable as starch in this respect. 
Fat is then much more valuable than carbohydrates in supplying 
heat to the body so necessary in cold climates. Fat is an essential 
part of the body and acts as a storehouse of energy which may be 
called upon when sufficient nourishment is not obtainable, as in 
some illnesses. It lubricates the tissues and prevents constipation 
by the same action on the bowel contents. 

The fat in the body is formed chiefly from carbohydrates and 
proteids in the food, the fat in the food being burned up for the 
immediate necessities of heat and muscular movements. Fat in 
abundance is particularly needful in weakness of the nervous system, 
as nervous prostration, in all wasting diseases, and in those predis- 
posed to consumption. 

Fat is not so readily digested as many forms of proteids and 
carbohydrates. Those fats which are fluid at the temperature of the 
body are generally most digestible. Butter, cream and bacon are 
most digestible among the animal fate and are those which are to be 
recommended. Some vegetables contain large amounts of fat, as nuts. 
Peanuts, for example, contain forty-one per cent, of fat and twenty- 
eight per cent, of protein. 

There is about five per cent, of fat, or a little more, in Indian 



CONSTITUENTS OF FOOD AND THEIR VALUE 287 

corn and oatmeal. Nuts are somewhat indigestible but very nu- 
tritious ; the peanut paste is more digestible than the whole nuts. 

A pure vegetable diet is too bulky for human beings, and when 
an ordinary mixed diet is not advisable a vegetable diet, including 
bread and cereals, may be combined with an abundance of fat in 
the form of butter and cream. Green vegetables and roots consist 
chiefly of water, seventy-five to ninety-five per cent. They are valu- 
able for their palatability and because their succulence, cathartic 
constituents, and indigestible residue, aid the action of the bowels. 

Certain properties are attributed to special vegetables. All green 
vegetables, especially spinach, are thought to be more valuable as a 
source of iron than other food. Onions contain sulphur; celery 
and lettuce contain principles having a sedative effect on the nerv- 
ous system ; new beets are digestible and contain considerable sugar ; 
cabbage and all the green vegetables (including potatoes) are rich 
in salts which are valuable in the body in assisting various processes. 

It is better to roast, steam, or cook vegetables in some other way 
than by boiling (which removes the salts), unless the water in which 
they are boiled is used for soups or stews. 

Cereals are the most concentrated of the vegetable foods. They 
contain from ten to fifteen per cent, of water, from ten to twenty per 
cent, of proteids, from sixty to seventy per cent, of carbohydrates, 
and from five-tenths to six per cent, of fat, besides phosphates and 
other salts of value to the body. Wheat, which may be regarded 
as most nutritious, contains thirteen per cent, of protein, sixty-six 
per cent, of carbohydrates and one and six-tenths per cent, of fat. 
There is fifty-five per cent, of starch in bread. 

The carbohydrates consist chiefly of starch that is enclosed in 
nature in cells which are ruptured by crushing, boiling, etc., so 
as to make the starch digestible. Raw starch, as in raw potatoes 
and bananas, is not digestible because the starch granules are un- 
broken and not so readily acted upon by the digestive juices. The 
cereals are now used largely for breakfast foods. Many of them 
are cooked and roasted to make the starch more digestible by con- 
verting it into dextrin. These foods are chiefly to be objected 
to on the score of too great bulk for the amount of nutriment which 



288 PERSONAL HYGIENE 

they contain, particularly the puffed and shredded varieties. The 
older cereals, as hominy, oatmeal, cracked wheat, Indian meal, 
graham meal, etc., if cooked for several hours, are to be advised for 
children in preference to the modern aerated cereal foods which 
appease the appetite without supplying sufficient nourishment. 

The whole wheat and rye flours are more valuable for making 
coarse bread which is suitable in constipation. 

Fruits consist almost wholly of water, apples containing eighty- 
four per cent, of water, two-tenths per cent, of protein, and fifteen 
per cent, of carbohydrates. Their acids, sugars, salts, and water 
aid the action of the bowels but they have little nourishment and 
should not be eaten between meals lest they spoil the appetite. 

Raw fruit is often harmful because unripe, and more often, in 
the case of quickly perishable fruits, as berries, contain germs and 
cause fermentation. Disease germs in manure (strawberries) and 
dust may also contaminate raw fruit. When the outer peel of fruit 
is not removed, cooking is desirable. Young children should only 
receive cooked fruit (except the juice of oranges), and for older 
children, apart from oranges and cherries, it were better that the 
fruit were not raw. Strawberries are a very common cause of 
digestive troubles, and even of appendicitis, probably from their 
contamination with germs in lying on the ground ; most persons can 
take the cooked berries. Bananas are indigestible for young chil- 
dren (unless baked) and the author has seen severe indigestion 
and even convulsions in infants from their action. 

In comparing the nutritive value of a meat and vegetable diet 
it may be said that vegetables must be eaten in much larger amounts 
to obtain the same nourishment, and that dried peas and beans, 
most nearly resembling meat in composition (beans, 25 per cent, 
proteids, 40 per cent, carbohydrates, 1 per cent, fat), are more in- 
digestible. 

The inorganic salts which are essential to the structure of bone 
and tissues exist to a sufficient extent in ordinary food, with the 
exception of common salt, which is necessary to form the digestive 
juice in the stomach, as well as being an important constituent of 
the fluids of the tissues. Salted foods, as salt pork, corned beef, 



CONSTITUENTS OF FOOD AND THEIR VALUE 289 

saltfish, etc., are indigestible because water is abstracted by salt 
from the food which is thereby rendered drier, denser, and harder. 

Water should be taken daily to the extent of at least six glasses, 
either pure or in the form of other drinks. It is better that half 
this amount be taken between meals so that the digestive juices be 
not unduly diluted, and that the food be properly chewed and mixed 
with saliva, and not simply washed down. 

Water is essential in dissolving food elements, in aiding escape 
of food from the stomach into the bowels and in assisting the move- 
ment of the undigested and indigestible matter in the intestines, and 
so preventing constipation. Drinking an abundance of water also 
assists in the elimination of waste matters from the blood in the 
kidneys, and prevents the urine from becoming so concentrated that 
irritation of the urinary tract and formation of gravel or stone might 
occur. 

An abundance of water stimulates the appetite and the forma- 
tion of fat — especially if taken at/ meals. Water should not be 
taken at meals at all, except in coffee, tea, milk, soup, etc., by persons 
trying to reduce weight. The drinking of great quantities of water, 
as several quarts daily, is inadvisable in causing dilation and inac- 
tion of the stomach (atony), especially in the case of cold water. 

The drinking of large quantities of hot water is also unwise, 
and ice water at meals tends to delay digestion. Some proteids and 
some fats are much more valuable than others, and fresh meat, 
eggs, milk, vegetables and fruits contain substances absolutely es- 
sential to growth and life (vitamines) absent in starches, sugars and 
fats {See pp. 589-91). 

In regard to ice taken in iced drinks or food, there are two 
sources of danger. One, when ice is made from polluted water 
in which human excrement and urine may furnish the germs of 
typhoid fever and diarrheal diseases; the other, that these same 
germs may contaminate ice through its handling by persons with 
dirty fingers, which not infrequently are soiled by their own excreta 
and these may contain the germs just noted. One would certainly not 
drink water in which such persons as servants and railway em- 
ployees had dipped their hands, and yet one is apt to do this 



290 PERSONAL HYGIENE 

every day of one's life unwittingly, in the form of melted ice. 
One may then avoid the dangers of ice, first, by using only ab- 
solutely clear ice, since ice from polluted water is apt to be dirty 
or cloudy — unless the germs and dirt have settled out of it; second, 
one may escape the dangers from contamination of pure ice after it 
is formed, by having it washed with pure water and not handled by 
those with dirty fingers. As the latter requirement is impossible 
of attainment in public service, ice water supplied for the public 
in hotels, cars, stations, and the like, should be made by such means 
that the ice does not come in direct contact with the water. 

TEA AND COFFEE 

It is a remarkable fact that the same chemical substance — 
caffein — is to be found in all the national beverages. of the world. 
It is the active principle in tea, coffee, and cocoa, in kola seeds 
used by the Africans, in guarana, drunk in the Amazon valley of 
South America, in mate tea, made from the leaves and shoots of 
a species of holly in Paraguay and Uruguay, while in ^Mexico and 
the West Indies the fermented chocolate beans are used which 
contain a principle (theobromin) closely allied to caffein. Uncon- 
sciously natives of various countries felt the necessity of a certain 
stimulating principle and discovered it independently in various 
plants. 

Both tea and coffee contain, besides caffein, a volatile oil, gen- 
erated in roasting coffee and occurring naturally in tea. Boiling 
water should be poured on both, but neither should be boiled, or 
the volatile oil or aroma will escape. If coffee is boiled long the 
water extracts matters from the bean which interfere with the 
digestion. If tea is steeped for some time the water dissolves tannic 
acid from the leaves which quite seriously disturbs digestion, has a 
tanning effect on the stomach, and lessens the amount of gastric 
juice. It is probable that the volatile oil in coffee is responsible 
ifor biliousness in some persons and it has a marked laxative effect 
in others, while tea — owing to its tannic acid — is constipating. 

Tea and coffee are direct stimulants to the brain, heart, and 
muscles. Experimentally it has been found that both increase the 



CONSTITUENTS OF FOOD AND THEIR VALUE 291 

capacity for mental and physical work. Stenographers can write 
better and longer and soldiers march further under caffein than 
without it. Tea or coffee are bad for persons with nervous indi- 
gestion. Both do much harm when taken in excess and in those 
who are poorly nourished, anemic, lead sedentary lives, and possess 
weak nervous systems, the effects are marked. Indigestion, in- 
somnia, palpitation, and rapid, irregular pulse, constipation (tea), 
headaches, neuralgia, and general nervousness, are among the more 
common symptoms. If any such symptoms arise it is always wise 
to at once refrain from taking tea or coffee, since only in this way 
is it possible to surely attribute the symptoms to the beverage. There 
are unquestionably many wretched nervous persons who are merely 
victims of caffein poisoning from tea or coffee. For an unusual 
mental test, a previous cup or two of coffee may bring out the best 
results, as in an examination, but an excess will cause nervousness 
and impede clear thinking. 

Chocolate is made from seeds of the chocolate plant, after they 
have been deprived of their shells (cocoa shells), sweated and dried 
(removes the tannin), and roasted; the latter brings out the flavor. 
Chocolate contains thirty to fifty per cent, of fat (cocoa butter), 
which retards secretion and motions of the stomach — like other fats 
— and it cannot be taken in large quantities for this reason. 

Cocoa is made by pressing some of the fat from chocolate, and 
contains from fifteen to thirty per cent, of fat. Poor cocoas are 
made by diluting cocoa with starch, and in Dutch cocoas the fat 
is partially saponified by the addition of an alkali. Chocolate and 
cocoa should be boiled about five minutes to dissolve the starch natu- 
rally present in the bean. Cocoa is more digestible than chocolate 
and is highly nutritious when made with milk. There is a Phillips's 
digestible cocoa in which the fat is predigested and it is particularly 
suited for those with weak digestion. 

Tea contains one to four per cent, of caffein, coffee from six- 
tenths to two per cent., and chocolate about the same amount of the- 
obromin and one-third to one per cent, of caffein besides. 



292 PERSONAL HYGIENE 

ALCOHOL 

While there are many differences of opinion in respect to alcohol, 
yet there are certain facts accepted by scientists which it may be 
well to state. 

That alcohol is of benefit to the healthy person living under nor- 
mal conditions it is impossible for any one to prove. But, on the 
other hand, it can be positively demonstrated that the habitual use 
of a moderate amount of alcohol, or the occasional use of an excessive 
amount, are capable of greatly damaging the health. 

It is, furthermore, an incontrovertible fact that alcohol may be 
of the greatest service in disease and, under certain conditions, in 
preventing disease. Again, while the occasional use of alcohol in 
moderation may not cause any visible injury in the average healthy 
individual, yet in some otherwise healthy persons its influence is so 
great that it becomes impossible for them to use it in moderation. 
Moreover, some individuals can habitually consume considerable 
quantities of alcohol without suffering any apparent detriment there- 
from (although their children may), while other persons, apparently 
as strong and living under the same conditions, will be completely 
wrecked by the same amount. 

Alcohol has been called by some a food, by others a poison. It 
is not ordinarily a food in health because the harm that it does 
completely overshadows its value in supplying heat and energy ; for 
example, its harm in being irritant in concentration in the stomach, 
in being destructive to tissues in the body in large amounts (espe- 
cially the liver), in its stupefying action on the brain, and finally 
in its tendency to encourage users to excess. 

Alcohol is a very expensive food and must be paid for in blood 
and coin. Alcohol is particularly harmful for frequent use by 
women and children but is often of positive benefit for the aged. 
Like tea and coffee, alcohol is much more injurious to the underfed 
than to the well-nourished individual. 

Alcohol has been called a stimulant. Its action on the brain 
is quite the contrary, and it is a narcotic or agent essentially de- 
pressing the brain. Like ether or chloroform, there may be a slight 



CONSTITUENTS OF FOOD AND THEIR VALUE 293 

preliminary exciting effect, but its chief action is progressive stupe- 
faction. 

Its first effect is to remove the highest mental quality, restraint 
(in vino Veritas), so that for nervous public speakers a small amount 
of alcohol may overcome the restraint and nervousness which inter- 
feres with free thought and speech, and the imagination in writers 
and the emotion in musicians may be stimulated ; but the habit is 
bad and the amount desirable is uncertain. The removal of the 
restraint exercised by the brain over the sexual desires is marked, 
and the first errors of youth are usually committed under the influ- 
ence of alcohol. Failure in judgment, inability to appreciate con- 
sequences, carelessness for feelings of others, and recklessness, follow 
the first effects of alcohol. Mental acts requiring accuracy are 
performed less well. 

Experimentally it has been found that typesetters make more 
errors, musicians strike more false notes, and that sight, smell, hear- 
ing, and touch are less keen under the influence of moderate amounts 
of alcohol, and memory and mental powers are much impaired. 

Coffee is the direct opposite of alcohol in its action on the brain, 
being a true stimulant, and actually improving the normal mental 
functions. After-dinner coffee tends to counteract the effects of al- 
cohol at dinner. 

As a stimulant to the circulation alcohol has always been par 
excellence the stimulant. It has so little effect in increasing the 
force of the heart that experimenters find no increase of blood 
pressure from its use; that it has any stimulating effect on the cir- 
culation, has been denied by reliable authorities. The consensus 
of scientific opinion, based on a vast number of experiments, is 
that alcohol in concentration (one part of whisky with two of water) 
stimulates the heart briefly from its irritant action on the mouth 
and throat (reflex action as from inhaling ammonia), and it has 
beside a very slight stimulating action on the heart itself; so that 
doctors do not rely upon alcohol in emergencies as a stimulant but 
have much more powerfully acting remedies. . 

In the case of accidents it is the agent most often at hand, and 
the sedative effect on the brain is often of great value. Alcohol 



294 PERSONAL HYGIENE 

causes at first greatly increased muscular power for a very short 
period, but after this time there is a marked loss of strength — 
sometimes to the extent of fifty per cent. Alcohol is then a had 
preparation for any work which requires judgment, memory and 
the utmost capacity of the special senses. 

As we have seen it is equally bad for sustained muscular work. 
It should only be used after severe muscular exertion and other 
unusual demands on the nervous system — never as a preparation 
for them. Alcohol greatly lowers the body temperature, especially 
when exposed to cold. It is related of certain explorers who were 
spending the night on a cold mountain top, after a hard day's 
climb, that some took no stimulant and turned in cold and miserable ; 
that others took whisky in moderation and retired feeling warmer 
and more comfortable; that the rest indulged freely in drink and 
slept oblivious of all cold and discomfort whatever. In the morning 
those who had refused alcohol awoke refreshed and well; those who 
had taken a little alcohol awoke very cold and wretched ; while those 
who had freely indulged did not awake at all, because they were 
dead. 

The bad effects of alcohol in health are often absent in sickness. 
The action of alcohol in increasing the pulse in health may be 
reversed in fevers where it may slow the pulse and reduce fever. 
But its use as a routine in medicine has largely disappeared, and 
there is a general tendency toward reduction in the social use of 
strong alcoholic drinks. 

Savages quickly succumb to the action of alcohol, and in the 
evolution of the race, the fittest survive. Thus families and indi- 
viduals addicted to alcohol tend to perish, and the disease becomes 
less prevalent. 

The effect of alcoholic beverages depends chiefly upon the amount 
of alcohol contained in them. Whisky, brandy, and rum contain 
approximately about fifty per cent, of alcohol; gin contains about 
sixty to seventy per cent. ; California hoch, Riesling, sherry, mus- 
catel, Madeira, claret, and the Ehine and Hungarian wines contain 
twelve to fourteen per cent, of alcohol; imported sherry sixteen to 
twenty-five per cent. ; champagne ten to thirteen per cent. ; ale, 



CONSTITUENTS OF FOOD AND THEIR VALUE 295 

stout, beer and porter three to seven per cent. ; and hard cider five 
to nine per cent. 

The stronger liquors should be diluted with only once or twice 
their bulk of water in emergencies. The bouquet or flavor of alco- 
holic beverages depends upon the development of certain alcohols 
(esters) in course of time. Whisky should not be used until four 
years old, as in this time the harmful fusel oil and Wood alcohol will 
be converted into the desired bouquet-giving esters. 

A sweet wine contains free sugar, while a dry wine is free from 
sugar because all of its sugar has been changed by fermentation 
into alcohol. A red wine is made by fermenting the juice of red 
grapes in the presence of their skins and contains some tannic acid 
which makes it somewhat rough. White wine is prepared from 
grapes free from skins, seeds, and stems. Scotch and Irish whiskies 
have a smoky taste from being distilled over peat fires, or being made 
from malt dried over peat fires. Gin is redistilled with juniper 
berries which makes it more useful in relieving pain, and gin is 
employed for this purpose by women during menstruation. 

A tremendous wave of prohibition is sweeping over this coun- 
try at the present time (1915), and indeed over the entire civilized 
world. The actuary of the New York Life Insurance Company has 
recently made a statistical study of the deaths of two million policy 
holders (picked risks) during twenty-five years. He states that 
"total abstainers have a mortality during the working years of life 
of about one-half that among those who use alcohol to the extent 
of at least two glasses of whisky a day." In other words, there are 
twice as many deaths among the drinkers (to the extent noted) 
as among the abstainers, during the period mentioned. 

TOBACCO 

The enormous use of tobacco renders its consideration of im- 
portance. The annual world output is something like two billion 
pounds. Unfortunately one cannot so glibly express in figures the 
results of its consumption. Let us first briefly consider its action 
on the body. 

Tobacco is a narcotic and is classed in books on drugs along with 



296 PERSONAL HYGIENE 

alcohol, opium, ether, etc. Narcotics are drugs which essentially 
produce stupor. In their milder action they are sedative and sooth- 
ing, while general unconsciousness and paralysis follow their most 
pronounced influence. 

But there is often a preliminary stage of stimulation, seen more 
markedly in the action of alcohol and ether. In the case of tobacco 
there is a primary, inappreciable stimulation of the nervous and 
circulatory systems, but the only immediate noticeable effect in the 
use of tobacco is the secondary, sedative or soothing action. 

After action comes reaction. This is seen following excessive 
smoking, especially when one stops using tobacco. The nervous 
system has become unstable and irritable, as shown by restlessness, 
walking about, and general "nervousness." There is still a much 
more remote influence of the long-continued use of tobacco and this 
may not be appreciated for years, or until middle life, when a gen- 
eral loss of vigor or some of the special results of tobacco become 
evident. It is very difficult to convince people of this secret, slow, 
undermining effect; it must be taken on trust. As in the case of 
disease, prevention is to be preferred to cure, and it is the boy and 
young man who must be prevented from beginning the tobacco 
habit. The present difficulty is that, as a rule, the persons who 
should have most influence in this good work — the parent or teacher 
— are handicapped at the start in being themselves tobacco users. 

Youth is a heedless animal, who recks little of the future, and 
it will be necessary to present the case impressively and truthfully 
to influence in any way his conduct. I shall not moralize, but will 
only furnish facts. 

Tobacco affects the circulation as it does the nervous system, 
that is, it first stimulates and then depresses the heart, and first 
contracts and secondarily dilates the blood vessels. In both in- 
creasing the action of the heart and contracting blood vessels to- 
bacco greatly increases blood pressure, temporarily, and it is gen- 
erally considered one of the causes of hardening of the arteries which 
occurs in middle or later life. The depressing effect of tobacco 
on the heart may lead to disturbance of its action. 

There are certain well-recognized troubles which physicians know 



CONSTITUENTS OF FOOD AND THEIR VALUE 297 

may be produced by the excessive use of tobacco. These are as 
follows : 

1. Disturbance of the heart, pain about the region of the heart, 
a fluttering feeling or palpitation of the heart, shortness of breath, 
and rapid, irregular pulse, are frequent results of tobacco. More 
rarely the pulse may be slow and blood pressure low from the action 
of an excessive use of tobacco. 

2. Irritability, mental depression, and lack of energy and ambi- 
tion commonly follow the overuse of tobacco owing to its baleful 
influence on the nervous system. Headaches, dizziness, and trem- 
bling of the hands are frequently present from the same cause. 

3. Tobacco has a locally irritating effect upon the mouth and 
throat. Dry, hot smoke is more irritating, so that smoke from 
cigarettes is most injurious in this respect. Soreness of the throat 
is common and the irritation is apt to extend up along the eustachian 
tubes, which lead from the upper part of the throat to the ears, and 
in this way deafness (catarrh of the middle ear) is not infrequently 
produced by excessive smoking. Cigarette smokers have often a 
peculiar, harsh, loud, ringing or barking, dry cough, and some harsh- 
ness or hoarseness of the voice, from the effects of smoke upon the 
vocal cords. In the mouth excessive smoking sometimes produces 
white patches on the tongue or inside the cheeks (leukoplakia) and 
one of these, after years, quite frequently ulcerates and results in 
cancer. Cancer of the lip is seen almost wholly in men, and is to 
be attributed often to the constant pressure of a pipe stem on this 
part. 

4. Indigestion of various kinds is occasioned by abuse of tobacco. 
That form associated with an increase of acid, which causes so- 
called heartburn, is common. 

5. The paralyzing effect of tobacco on special nerves (optic nerve) 
is seen in partial blindness or dimness of sight due to excessive 
smoking ; vision is usually better in a poor light. Deafness may also 
be caused by the direct action of tobacco on the auditory nerve, as 
well as by its effect in producing catarrh of the middle ear, which 
has been noted. 

All of these troubles are not frequent occurrences in individual 



298 PERSONAL HYGIENE 

smokers, or the habit would suffer in popularity, but in the aggre- 
gate there are a tremendous number of such cases and one may 
never know whom it will affect. In a general way, nervous indi- 
viduals and those working indoors withstand tobacco poorly as com- 
pared to the phlegmatic individual and the outdoor worker. These 
morbid conditions are usually quickly removed by complete absten- 
tion from tobacco and by adopting a healthy manner of living with 
outdoor exercise. In fact, in the presence of one of these troubles, 
it will be impossible for the physician to certainly know that tobacco 
is the cause unless the habit is stopped for some weeks. 

There are still other serious moral and physical results from 
the use of tobacco by the young. By careful study of the students 
at Yale and Amherst colleges it has been found that the growth of 
smoking students is decidedly checked by excessive use of tobacco 
and that the height, weight, and chest measures of smokers are below 
normal. At Columbia College, Meylan found that the use of to- 
bacco leads to idleness, lack of application, ambition, and scholarship. 
The celebrated lay specialist in drug habits, Charles B. Towns, 
states that in his opinion tobacco diminishes the efficiency of the 
smoker about fifteen per cent., and he regards the use of tobacco 
as more serious than addiction to alcohol, opium, or cocain because 
"the total harm done by tobacco is greater (i. e., in the aggregate) 
than that done by alcohol or drugs. Nothing else at the present 
time is contributing so surely to the degeneration of mankind as 
tobacco.'' 

Towns finds that he cannot cure alcoholism, except in persons of 
the strongest character, when they continue the use of tobacco. He 
finds that almost all alcohol and drug habitues smoke also, and that 
excessive smoking is almost sure to lead to drinking. The nervous 
depression produced by smoking causes a natural desire for alcohol, 
just as the depression caused by opium is relieved by alcohol. 

Besides the chief poison in tobacco, nicotin, there are allied sub- 
stances, as pyridin, collidin, etc. Nicotin ranks with prussic acid 
and aconitin as the most powerful poisons known. One-twentieth 
part of a drop is a dangerous dose, and there is enough nicotin 
in a cigar to kill two men — not habituated to tobacco — providing 



CONSTITUENTS OF FOOD AND THEIR VALUE 299 

it could be all absorbed into the blood. Nicotin is a colorless, vola- 
tile, oily, acrid liquid. In Virginia tobacco there is two to six 
per cent, of nicotin ; in Turkish tobacco from two to five per cent. ; 
in Havana tobacco from one to three per cent. In tobacco smoke, 
besides nicotin, there is another toxic substance, furfurol. This is 
an ingredient of fusel oil, the body in new whisky, which gives 
rise to headache and other troubles. There may be indeed as much 
furfurol in one cigarette as is contained in a wine-glass of whisky. 
It is often absent in Turkish tobacco. The taste, and flavor, and 
to some extent the strength, of tobacco is due to a volatile oil de- 
veloped in curing. 

Much of the nicotin is destroyed in smoking or burning tobacco 
— from one-fifth to four-fifths, in fact. Nicotin being volatile, that 
which is not burned is largely inhaled with the smoke. The drier 
the tobacco the more rapidly it burns and the greater the destruction 
of nicotin. In this respect cigarettes are least harmful. The mild- 
est cigars are thin and dry. In smoking thick, moist cigars there 
is a hot, damp, steaming area behind the flame which is most favor- 
able for the volatilization of nicotin. 

Lee performed an interesting experiment which shows how much 
more nicotin is destroyed in smoking cigarettes than in smoking 
cigars. The same amount of tobacco was burned in a cigar and 
cigarette, but the cigarette tobacco contained double the amount of 
nicotin. Nevertheless, the smoke of the cigarette contained but 
half the quantity of nicotin found in the smoke of the cigar. 

Notwithstanding all this, ordinary cigarette smoking is the most 
injurious. Pipe smoke is stronger than either that from the cigar 
or cigarette. This follows because in the bottom of the pipe bowl 
there accumulates a sharp, pungent, moist admixture of saliva and 
tobacco. This is not nicotin, as commonly supposed, but is rich 
in the poison. In smoking the heat distills off nicotin from this 
moist sediment and it is inhaled in the smoke. There is about as 
much tobacco in five or six cigarettes as in one average cigar. A 
moderate smoker may be considered one who smokes a single cigar 
daily after dinner. 

The cigarette is most harmful for several reasons. Foremost, 



300 PERSONAL HYGIENE 

cigarette smoke is usually inhaled. This brings the smoke in con- 
tact with an enormous lung surface for absorption. The lungs are 
made to absorb gas (air), and the effect of drugs inhaled is much 
more rapid than when swallowed; hence the instant action of 
laughing gas, and the reason why opium is smoked by addicts rather 
than swallowed. Cigarette smoke is so mild that smokers find little 
pleasure in merely drawing it into the mouth and throat, as in smok- 
ing cigars and pipes, but they must inhale it to secure the full drug 
effect on the system. If a person were to smoke two or three ciga- 
rettes daily, and never inhale the smoke into the lungs, the influence 
upon the health would be negligible. 

Formerly, when only pipe and cigar smoking were available to 
youth, the liability to dreadful nausea and collapse, and the expense 
acted to dampen the enthusiasm for initiating this manly habit; 
now the cheapness and mildness of cigarettes (which sometimes even 
are drugged to prevent nausea) lead to their use by boys at an 
early age. The cost is so slight that they are smoked at all available 
moments when there would not be time to smoke a cigar or pipe. The 
inhaling and the constant smoking are then the chief dangers of 
the cigarette. The local, irritating effect of the smoke upon the 
throat is greater than that from the moister cigar and pipe smoke, 
as has been said. 

Boys are often forced to smoke surreptitiously and this brings 
them into low companionship and surroundings, as the tobacco stall, 
pool and barroom, when a vicious circle is established. Towns 
affirms that average opium smoking does no more harm than average 
tobacco smoking with inhalation. 

Why does one smoke ? A smoker would feel hard put to it to give 
a more precise reply than that he liked the sensation. Smoking is 
partly a narcotic and partly a psychic habit. Its narcotic influence 
is exemplified in its soothing, quieting drug action, in relieving 
anxiety and worry, and in producing a pleasant frame of mind. 

Its psychic action depends upon the presence of an object in 
the mouth (as an infant sucks a blind nipple), upon the rhythmical 
inhalation and exhalation, and the hypnotic effect of watching the 
smoke curl into fascinating and fantastic forms and rings. For 



CONSTITUENTS OF FOOD AND THEIR VALUE 301 

the reason that there is not so great a physiological demand of the 
system for nicotin, or craving, as for alcohol, opium, or cocain in 
habitues, it is easier to break off the habit abruptly. One then 
satisfies the psychic demand by chewing gum, quassia, gentian, or 
by eating candy, and the craving does not grow unless in the case 
of the inveterate smoker. 

In addition to the ease and comfort of mind produced by smoking 
there are the less desirable mental effects which lead to laziness, 
lack of energy, and the tendency to avoid responsibilities and duties. 
In the present day efficiency is worshiped as a fetich and its lack 
is unhappily only too horribly patent in the present great European 
war. This is the feature which should prevent the youth from 
beginning the habit. 

We have already noted that, in the opinion of an expert in drug 
habits, tobacco smoking diminishes one's efficiency about one-sixth. 
Youth realizes that success in business and sport is largely de- 
pendent upon personal energy and vigor. The tennis or billiard 
player is notoriously not up to his best when saturated with tobacco 
smoke on account of the resulting unsteady nerves. 

The matter of tobacco is in like case with other harmful habits, 
for no sensible person will affirm that tobacco improves the health. 
It simply becomes a question of how much injury tobacco does. 
This depends upon the personal constitution, the amount of tobacco 
absorbed, and the occupation of the individual. Its effects may 
be imperceptible in the parent but may lead to a defective nervous 
system in the offspring, as is indisputably true of alcohol. If we are 
smokers we must confess ourselves fools to our sons in praying them 
to improve upon their fathers. 



CHAPTER III 
PERSONAL HYGIENE (Continued) 

General influence of exercise and of excessive exercise. Exercise for dif- 
ferent ages. 

EXERCISE 

Exercise in General. — Reference is made here to that form 
which is "usually thought and spoken of as muscular exercise. There 
are involuntary muscles, so called because they are not under con- 
trol of the will — as the muscles of the heart, digestive tract, blood 
vessels, and diaphragm. 

, A muscle is made of numerous small, microscopic fibers bound 
together in bundles and attached usually to the bones — in the case 
of voluntary muscles — at either end by a white, strong tissue in 
the shape of a cord. Muscular action consists of a shortening and 
thickening without change in bulk. In this way one bone is moved 
upon the other. 

But the muscle is only part of a mechanism necessary to muscular 
action or exercise. The mechanism concerned in exercise is a neuro- 
muscular (nerve-muscle) one. In this mechanism there is the nerve 
center in the brain, the nerve which carries impulses from this to 
the spinal cord, nerves which transmit impulses to the muscle from 
the cord, and the muscle itself. 

Muscular action may be voluntary, automatic, or reflex. In 
voluntary action an impulse originates in the brain and travels 
along the circuit just described at the rate of about two miles a 
minute until it reaches the muscle and results in contraction. Auto- 
matic action is sustained by impulses which are sent from the 

302 



EXERCISE 303 

central nervous system to the muscles without conscious knowledge 
or volition, as occurs in the case of the heart beats and movements 
of the digestive organs. 

Reflex action happens when an impulse, started by some irrita- 
tion of a nerve of sensation, is conveyed by that nerve to the brain 
or spinal cord, and is there transformed into an impulse which 
travels along the motor nerve of a muscle and results in contraction 
of the muscle to which the nerve is connected. Reflex action occurs 
independently of the will, as when winking follows touching of the 
eyeball, or when the sole of the foot is tickled and the foot moves. 
Such action may take place when the subject is asleep or unconscious, 
or in spite of attempted opposition by the will. 

In addition to the nervous impulse there must be a sufficient 
supply of fuel and force brought into the muscle. This, as we 
have seen in the consideration of the role food products play, con- 
sists chiefly in the combustion of sugar in the muscles by oxygen 
brought to them in the blood. The result is the production of heat 
and muscular work or contraction. Exactly what a nervous impulse 
is and just how the oxidation of sugar (in the form of glycogen) 
results in muscular contraction we do not know. Although sugar 
is the favorite fuel for muscular action, yet meat and fat may be 
used as fuel in place of starches and sugar. Sugar is one of the best 
stimulants to the muscle during unusual exertion. 

Muscular fatigue is due to three causes: failure in the food 
supply of the muscle ; accumulation of waste products from chemical 
changes occurring in the muscle, and failure of the nervous system 
to transmit impulses. 

Nervous insufficiency may be due to the paralyzing effects of 
the waste products in the muscle acting upon the nerve endings, or 
to alterations in the brain cells which have been detected micro- 
scopically after overuse of the muscles in animals. In any event one 
should keep in mind that efficiency of the nervous system in mus- 
cular exercise is the most essential factor. It is indeed quite gener- 
ally recognized that nervous activity and force is of great value in 
even purely physical contests, and conversely, that in nervous exhaus- 
tion or prostration, muscular power is sometimes almost abolished. 



304 PERSONAL HYGIENE 

Effect of Exercise on the Body as a Whole. — In muscular ex- 
ercise there must also be nervous exercise. Just as a muscle grows 
larger, firmer, and stronger by exercise, so the brain and nerve 
cells become more efficient in the way of rapidity, acuteness, and 
precision of movements. Exercise of the muscles develops the 
brain then to a certain extent. 

During muscular work the combustion of fuel in the muscles gives 
rise to much heat and waste matter. The heart beats are increased 
in number and force. This follows for several reasons: the waste 
matters circulating in the blood, the increased blood supply to the 
heart, and the increased temperature of the blood stimulate the 
heart. When a muscle contracts, the arteries conveying the blood 
from the heart, widen and shorten and permit a freer circulation 
of blood. 

The veins, which carry the blood from the muscles to the heart, 
possess valves which prevent the blood from flowing back away from 
the heart. During muscular contraction the veins are compressed 
by the muscles, and this compression has the effect therefore of 
forcing the blood on toward the heart. Thus the amount of blood 
which flows through a muscle during exercise has been found to be 
three times greater than when a muscle is at rest. Thus muscles 
have been likened to hearts, and the heart in its turn is but a large 
muscle. The greater quantity of blood which flows through the 
heart during exercise stimulates it to contract more forcibly, and 
the action being more rapid — for the reasons stated — and the organ 
being itself more fully nourished by its increased blood supply, it 
follows that the heart grows larger and stronger like any other 
muscle. 

The breathing is also stimulated and becomes more rapid and 
deeper; this is because the waste matter (carbonic dioxid) formed 
during muscular action stimulates the respiratory centers in the 
brain. Thus more oxygen is taken into the lungs and carried in 
the blood to the muscles where it is used in burning the fuel for 
muscular activity. 

Notwithstanding the increased heat formed by the muscles dur- 
ing exercise, the temperature of the body is but slightly raised by 



EXERCISE 305 

the most violent exertion, because the increased circulation in the 
skin brings more blood to the surface. This condition allows of 
greater loss of heat from the skin and stimulates the sweat glands 
so' that there is a large escape of heat from evaporated moisture. 
An enhanced blood supply in the digestive organs favors improved 
digestive capacity and appetite. 

Excessive Exercise.— What is considered excessive exercise de- 
pends upon many circumstances. In youth the heart is apt to suffer 
from continuous and violent exercise, as in prolonged, competitive 
athletic contests. If the strain is sudden and violent, the heart may 
become dilated and weakened; if continuous, the heart is prone to 
become an enlarged and overgrown muscle, so that it is too strong 
and powerful for existence in ordinary life, and not having enough 
resistance to overcome in sedentary occupations, may cause distress 
by beating irregularly and tumultuously. The enlarged and thick- 
ened heart may weaken in time and dilation occur. The valves of 
the heart are also sometimes strained. 

The best exercises are those which develop the body generally 
by bringing into action large groups of muscles instead of small 
groups by special exercises. Moreover, in these exercises of large 
groups of muscles the beneficial action on the vital organs — already 
noted — is brought into play, while in the development of special 
muscles there is less effect on the vital functions. Thus running, 
swimming, rowing, wrestling, fencing, riding, boxing, dancing, are 
all good general development exercises. 

It is also well to promote special development of any part of 
the body, which is naturally deficient, by means of gymnasium work 
adapted to the individual requirements. Any violent exercise is 
unwise after middle age. 

Old age is largely due to the hardening and diminution in size 
of the arteries. Not only is this state favored by the strain on 
the vessels, caused by a pounding heart from violent exercise, but 
the dangers of hardening of the arteries are greatly increased when 
they are subjected to unwonted strain (apoplexy). Hard labor is 
indeed one of the chief causes of arterial hardening and it appears 
earliest in the manual worker. Arterial hardening must come sooner 



306 PERSONAL HYGIENE 

or later, as it is synonymous with old age. Our aim should be to 
defer the change as long as possible, and limit it to as small an 
area in the body as may be. 

Exercise for Different Ages. — The form of exercise which is 
most suitable for children consists in outdoor play which does not 
tax the nervous system as do exercises involving the precise move- 
ments necessary to the skilled use of tools. Then all the games and 
exercises calculated to promote general development, which we have 
noted, are advisable. When the nervous and muscular systems are 
well developed it is time for exercises requiring precision' of move- 
ment to be undertaken, such as the handicrafts, special lines of 
manual training, the use of musical instruments, etc. The period, 
after which these exercises are suitable, is about the fifteenth year. 

In young adult life there may be an excess of exercise, while 
the business man is too frequently chiefly occupied in sitting, eating, 
and sleeping. The young man should lose no chance of developing 
his body, for it is the aim of athletics to develop those qualities 
so necessary to any successful career — energy, strength, endurance, 
courage, alertness, persistency, and stamina. 

He should walk when he may ride, he should run when he might 
walk, he should climb stairs when he can take the elevator. Swim- 
ming, skating, rowing, hunting, fishing, and dancing are open to 
him. Home athletics and exercises may also be his. 

The various systems of exercises advertised often include the 
development of certain muscles by resisting movements with oppos- 
ing muscles, while concentrating the mind upon the process. This 
may build up a strong physique but makes one ''muscle bound" 
and unfit for skilled sports, where alertness and the bringing into 
action of many groups of muscles are requisite. 

The various exercises, consisting in bending the body and move- 
ments of arms and legs, which are the basis of many systems and 
may be practiced at the home, are undoubtedly of value, but it is 
generally conceded that exercise to be most beneficial should at 
the same time be agreeable. This contradicts the favorite theory 
of our parents that the ax and chopping block should prove a suf- 
ficient pastime to the restless and play-loving youth. 



EXERCISE 307 

Indeed this is the great bugbear of the prescribed exercise of 
the physician to the middle-aged patient. Exercise has become a 
lost joy and art and therefore a bore. One should not make a 
business but a pleasure of exercise. Walking is the cheapest and 
easiest form of exercise for the middle-aged and beyond. The mind 
should not be occupied with one's cares and duties, however, but 
one should "go about admirin' 'ow the world was made." Fatigue 
should be avoided, as the poisons developed in muscular fatigue 
are one of the causes of hardening of the arteries and old age. 

It is often stated in books on hygiene that an adult should per- 
form daily an amount of exercise equivalent to walking nine miles 
on a smooth level road at the rate of three miles an hour. This does 
not help the average individual much who does not indulge in pedes- 
trianism. 

The aim of exercise for the middle-aged and elderly should be 
the reverse of that proper for the young. The former should not 
run for a car, or upstairs, or carry a trunk, or undertake any un- 
necessary, violent exertion. Golf, motoring, riding, gardening, fish- 
ing, hunting, bird study, bowling, and moderate bicycle riding are 
suitable up to ripe old age. Such exercise as boxing, fencing, tennis, 
and hand ball induce too much nervous tension, while running, row- 
ing, swimming and basket ball strain the heart and blood vessels. 
The safest exercise for the elderly are walking, carriage riding 
or motoring, and billiards. 

However, for those who have kept in good muscular condition 
by constant exercise throughout their lives many of the more strenu- 
ous exercises may be followed to the end, as horseback riding. The 
writer knows a former member of our cabinet who played tennis 
well till long past sixty. 

To attain longevity one must take an active interest in life. 
"Hold on to life and life will hold on to you." And again, the 
ideal life is to be "active as long as possible, and then die as sud- 
denly as possible." 

In this strenuous and muscular age it is malapropos to hint 
that arduous exercise may not be necessary to an active and healthy 
existence. A vast number of persons live active (as opposed to 



: : S PEKSONAL HYGIENE 

sedentary) lives in perfect health, without taking exercise apart 
from that requisite to their vocations. The manual worker fa ;:' 
course not included in this category. Mental exercise appears to 
- us e sol statute for muscular exertion. The banker and clergyman 
are more long-lived than the farmer, and the most noted thinkers, 
foremost leaders in business, profe— : „-. art, science, and literature 
have, more often than the Samsons, been numbered among the 
octogenarians. 

There is no doubt that exercise in the open air is of the utmost 
value in youth in promoting general development of the mind and 
body, and that the country is the place to rear children. There 
fa also no doubt that sudden and violent exercise repeatedly per- 
formed — as in competitive, athletic contests — or that overuse of 
certain muscles, are injurious. 



CHAPTER IV 
PERSONAL HYGIENE (Continued) 

HEREDITY 

Heredity, broadly considered, consists in transmission of certain 
characteristics from parents to offspring. More precisely, heredity 
is the transmission of properties through the union of the contents 
or plasm of the germ cells of the parents to form a single cell — 
the potential new individual. 

By germ cells are meant those cells in the female which give 
rise to the egg or ovum in the ovary, and those cells in the testicle 
of the male which form the spermatozoon, the essential body in 
the secretion (semen) of this organ. Conception, following the 
sexual act, occurs when one spermatozoon in the semen of the male 
unites with one egg in the womb of the woman. The egg is set 
free from the ovary of the woman and finds its way down into the 
womb. It will thus be seen that the germ cells do not unite directly 
but indirectly through the products of the germ cells — the spermato- 
zoon and ovum or egg. 

The single cell formed by the fusion of the spermatozoon and 
ovum undergoes division into new cells. Some of these are set apart 
to form the germ cells in the offspring. The rest of the newly 
formed cells undergo great changes or are differentiated, so that 
they form such varied structures, as teeth, hair, nerves, etc., or all 
the structures of the new individual. But the germ cells situated 
in the testicle of the male or in the ovary of the female remain 
unchanged and are passed on from generation to generation without 
end — constituting the great marvel of heredity. 

309 



310 PERSONAL HYGIENE 

The infinitesimal plasm of the parental germ cells, which is 
contained in the new germ cells in the sexual organs of the offspring, 
is held in trust, until such a time as one of these germ cells unite 
with one of the opposite sex, and so in turn transmit its inherited 
characteristics to a new generation. 

How much are these germ cells sequestered in the sexual organs 
of the parent affected by the life of the parent; in other words, 
how much may the life of the parent influence the physical char- 
acter of the offspring? 

The modern popularly accepted doctrine of Galton and Weis- 
mann does not recognize such a parental influence — this means that 
the acquired characteristics of the parent may not be inherited by 
the offspring. With this we do not, however, agree. Such charac- 
teristics acquired by the parent, as special muscular or mental de- 
velopment, or skill, manual dexterity, and, on the other hand, ac- 
quired defects or mutilations (amputations) cannot indeed be in- 
herited. 

The cutting off of tails in generations of animals, and the ritual 
circumcision of Jews through endless generations, do not lead to 
similar defects in the offspring. The same sort of peculiarities 
in animals (short tail) may, however, originate spontaneously and 
be transmitted regularly to posterity. Such peculiarities may be 
due to some accident in the fusion and development of the germ 
cells of the parent. Marked cases occur as freaks or "sports," such 
as a tulip possessing seven petals instead of the normal six petals. 

In man we see like peculiarities in the webbed or short Angers 
and toes, and in the increased number of toes which are inherited 
in some families. Indeed, individuals possessing these peculiarities 
may often be prepotent, that is, may tend to transmit them in 
most cases even when mated with more normal individuals. 

Reversion to a former type of ancestry is another cause of varia- 
tion in individuals. Three types of reversion are recognized: first, 
the tendency seen in offspring to depart from the parental characters 
to that type common to their ancestry as a whole; second, to some 
particular ancestor; third, the reproduction of the original type of 
the first ancestors. 



HEREDITY 311 

Atavism is used in the sense of reversion to ancient types, but 
it more properly refers to reproduction of remote ancestral condi- 
tions of as high or higher type, while reversion means reproduction 
in the offspring of characters of a lower type. As exaggerated types 
of reversion we have the rare occurrence of several breasts in women, 
and the occasional appearance of stripes in horses, suggesting the 
zebra and probably the original horse. 

When individuals of different races marry, the offspring of the 
first generation may combine the characteristics of both parents, 
or resemble one parent in one respect and the other in another, but 
in the later generations there is a tendency in the offspring to 
revert to one or the other of the original parental types. Thus fol- 
lowing the union of a white and negro, after several generations 
of mulatto or nearly or completely white children, there may be a 
black child born of white parents. In offspring of widely sep- 
arated stocks, or of mongrels or half breeds, there is a marked ten- 
dency to revert to the original type of the species. In crossing two 
distinct breeds of pigeons Darwin found the offspring to possess 
all the characters of the wild pigeon. In the mating of a tame 
white mouse with a piebald Japanese waltzing mouse, von Giata 
reports the progeny to have been a wild gray mouse. 

Degenerates are descendants of parents of the same stock who 
tend to revert to a lower type, in size and shape of head, and moral 
and intellectual development. Contrariwise, within certain limits, 
the crossing of distinct stocks may lead to a higher type of offspring. 

For in Canada, Adami notes that the progeny of the mixed 
Anglo-Saxon and French are superior mentally and physically to 
the children of parents both French, or both Anglo-Saxon. 

Children may inherit some characteristics from one parent and 
others from the other parent, as the coloring of one and the features 
of the other. The color of the eyes is often an exclusive inheritance 
from one parent. When one parent has light and the other dark 
eyes, their children will possess either light or dark eyes — rarely 
eyes of an intermediate color. When the parents markedly differ, 
the offspring may resemble but one parent. Again, the progeny may 
combine the characters of the parents — when they differ in any nota- 



312 PERSONAL HYGIENE 

ble respect — as when the child of a very short and a tall parent is of 
intermediate height. 

In the so-called blended inheritance the child more commonly 
occupies a middle position between the characters of the two parents, 
while sometimes the child is generally superior to the parents, and 
occasionally shows qualities possessed by neither. Then, as we 
have seen, the offspring may revert to a former type and be superior 
or inferior, or the child may exhibit some sport or freak not so 
readily explained. 

At times the character of one parent lies dormant (recessive) in 
the offspring, only to reappear in a later generation, owing to the 
fact that some constituent of the germ plasm of one parent par- 
tially neutralizes or replaces the similar constituent in the other 
parent. But when the germ plasm of one parent is so powerful as 
to completely neutralize that of the other, the characteristics of 
the neutralized parent may never appear in later generations. There 
are certain remarkable laws governing inheritance which have been 
discovered by famous investigators as Mendel, Galton, and Pearson, 
but as these involve abstruse mathematical problems they will not 
be considered here. 

Certain racial characteristics in regard to disease are trans- 
mitted by inheritance. Thus negroes possess a special degree of 
immunity to malaria, while on the other hand they are peculiarly 
susceptible to tuberculosis — indeed all savage people are more sus- 
ceptible to the germ diseases of civilized races. Measles is an ex- 
tremely fatal disease in aborigines. 

Certain inheritances are peculiar to certain species of animals. 
Animals in general are immune to the contagious diseases affecting 
the sexual organs of man (syphilis, gonorrhea), and to typhoid fever. 

]Now let us turn again to the question of the inheritance of 
characteristics acquired during the life of the parent. 

We may make the rather startling statement to begin with that 
no special disease is inherited. Those most often regarded as in- 
herited diseases are syphilis and tuberculosis. As a matter of fact, 
children are very rarely born with tuberculosis and when they are 
it is because of infection from the mother's blood. True inheritance 



HEREDITY 313 

would mean that the disease germ resided in the spermatozoon of 
the father or the egg of the mother at the time they fused to form 
a new cell or individual. 

The germ cells of human parents do not contain microbes. To 
show the probability of the inheritance of tuberculosis from a con- 
sumptive father it has been found that there are not more than 
ten germs of tuberculosis in the semen of a consumptive. But in 
the semen there are some two hundred and twenty-six million sper- 
matozoa. As only one spermatozoon of the male combines with one 
egg of the female to form a new individual, the chances of infection 
from a male parent are practically nil. 

The same applies to other germ diseases. They are not strictly 
inherited ; that is the microbes are not conveyed in the egg of the 
female and the spermatozoon of the male when they fuse at con- 
ception to form the new individual. 

But it is well known that children of parents suffering from 
certain germ diseases are born with the same disease. How is this 
to be explained if the diseases are not inherited? In such cases 
the diseases are acquired by transmission of the germ from the blood 
of the mother to the child in the mother's womb; or germs of 
disease of the womb or sexual passages may enter the child while 
still in the body of the mother. When disease is thus acquired by 
the child, and not inherited, it is said to be congenital, or literally 
a "born with" disease. 

While in the mother's body the child may acquire disease by 
entrance of germs into it during its passage from the womb at birth. 
In this manner do children become affected with that dangerous 
form of inflammation of the eyes which is the source of blindness in 
most cases when the child is said to have been born blind. Ten 
thousand cases of such blindness exist in this country to-day. 

But while diseases are not strictly inherited, but acquired by 
the unborn child in the mother's womb, the child is vastly more 
influenced by the action of chemical substances on the germ cells 
of the parents. 

Life itself is largely a matter of chemistry. The size, shape, 
and structure of organs are due to their chemical composition. 



314 PERSONAL IIYGIEXE 

While the germ cells of the parents are not at all altered by 
maternal impressions either at conception, when the cells are free 
from connection with the body, or during pregnancy when the child 
is already formed completely (after the second month), yet they are 
tremendously influenced by poisons circulating in the blood of either 
parent. Here again one must distinguish between poisons in the 
mother's blood, which are conveyed directly to the child in her 
womb, and poisons which act on the germ cells before conception has 
occurred. Thus in the common form of poisoning in pregnancy, 
in which the mother has convulsions, the child also frequently suffers 
after birth from the same attacks, if not born dead. This is not 
a case of inheritance but of acquired poisoning of the child in the 
womb from the mother's blood. 

We will, therefore, consider the influence of chemical poisons 
upon the germ cells of the father, for such cannot in any way enter 
the blood of the offspring before birth, as in the case of the child 
in its mother's womb. 

There are three sources of such poisons in parents: poisons may 
enter the body from without, as in the case of alcohol ; they may be 
commonly generated from within by the germs of disease ; or they 
may be formed as the result of the internal secretions of glands. 

The children of fathers poisoned with alcohol, lead, or mercury 
are born dead, die young, or suffer from poor vitality and often 
from epilepsy or insanity, and these diseases are passed on from 
generation to generation. Experiments by Stockton have shown 
the same result in animals. He mated twenty-four male guinea 
pigs (previously chronically poisoned by alcohol) with as many 
normal females. The progeny consisted of but five living guinea pigs 
at two months of age, seven having died of convulsions soon after 
birth. The average progeny of twenty-four normal pairs of guinea 
pigs should be about one hundred young. 

The same results are seen in the offspring of human parents 
suffering from germ diseases, as syphilis. The children are fewer 
in number, are prone to be born dead or with monstrosities. They 
also have little vitality, die young, or are poorly developed, often 
have convulsions, and are epileptic or insane. These effects are 



HEREDITY 315 

not due to having inherited the actual diseases, from their parents 
but are due to the effect of the parental poisons on the spermatozoon 
or ovum. 

In other words, the children have inherited acquired characteris- 
tics from their parents in that the germ cells from past generations 
have been altered by chemical poisons while in the bodies of their 
parents. 

The natural secretions of many glands of the body contain 
chemical substances which have the most marvelous influence upon 
the growth and function of organs. Thus the wonderful change 
which occurs in the development at the time of puberty is in large 
measure probably due to the internal secretions of the sexual organ 
which are absorbed into the blood. The giant is the result of the 
secretion of the abnormal pituitary gland. Monsters, as cretins, are 
formed through the insufficient secretion of the thyroid gland in 
the neck. It is now known that conditions of these glandular 
organs acquired by the parents will so alter their germ cells that 
their children are apt to inherit allied conditions — the effect of 
chemical substances on the germ cell. 

In consequence of both parents having goiter, the children are 
likely to be cretins. In goiter (an enlargement of the thyroid gland 
in the neck) there is deficient secretion. In the cretin the secretion 
is so slight that the child becomes hideously distorted, an imbecile, 
a dwarf, with great head, swollen protruding tongue and lips, large 
belly, and stumpy tottering limbs. 

There is one more effect of the poison in the parent on the germ 
cells, whereby the offspring suffers, which should be emphasized. 
There appears to be an increased susceptibility, on the one hand, 
to the same diseases which in the parent caused the development 
of this poison, and, on the other, an increased susceptibility to the 
poison itself. Special poisons have a weakening action on special 
organs, so that the children of diseased parents are more susceptible 
to the diseases of their parents. It is the lessened resistance to 
certain diseases which is inherited rather than the disease itself. 
This is the explanation of so-called hereditary diseases. The 
tendency and not the disease is inherited. So with poisoning, the 



316 PERSONAL HYGIENE 

children of alcoholics appear to be much more susceptible to the 
effect of alcohol than are normal persons. 

When the parental system is poisoned by the products of disease, 
the nervous apparatus of the offspring is most apt to suffer since 
it is a law that the more recently developed organs in the evolution 
of man are the first to succumb to such injurious agencies, and 
the nervous system is the most recent product of bodily development. 

Not only may the predisposition to a certain morbid acquirement 
of the parent be inherited by the offspring, but this characteristic 
is likely to appear at the same time of life at which it appeared 
in the parent. Certain natural characteristics are similarly in- 
herited, such as the tendency to longevity. The best way to attain 
long life is to have had long-lived ancestors. The following dis- 
eases are those commonly said to be inherited, although, as has 
been stated, it is the tendency to the disease and not the disease 
itself which is transmitted. Nearsightedness, astigmatism, color 
blindness, deafness, obesity, diabetes, some forms of Bright 's disease 
of the kidneys, gout (more often in the male line), rheumatism, 
syphilis, tuberculosis, cancer, some skin diseases, and especially 
many nervous diseases as neuroses, epilepsy, hysteria, paralyses, and 
insanity. The occurrence of albinos and bleeders may be attributed 
to inheritance. 

Since the predisposition to disease may exist in those descended 
from a common ancestry, it follows that marriage between relatives 
is inadvisable because such tendencies may be doubled in intensity 
in their offspring. The likenesses existing between brothers and 
sisters is greater than between parent and child; while the rela- 
tionship existing between first cousins is practically the same as 
that between great grandparent and offspring. The children of 
early and late marriages are not apt to be so robust as those result- 
ing from marriages occurring at the most favorable time — the age 
of twenty-five for a man and twenty for a woman. There are many 
exceptions to this rule depending upon the health of the parents, etc. 

It is said that the child inherits the features, shape of the head, 
sense organs, and constitution from the father, while the mental 
characteristics may be transmitted from either parent, the shape 



HEREDITY 317 

of the trunk and internal organs more closely resembling those 
of the mother. Such a statement must be accepted with considerable 
salt. 

Sumnrary. — We have endeavored to show that not only are the 
chief characteristics of the parents transmitted in their germ cells 
from generation to generation, but also that acquired characteristics 
of the parents — especially due to chemical influences from without 
and within — may be transmitted to their offspring. 

But what shall be said of the vast importance of environment ? 
Persons are apt to be carried away by one side or other when 
considering the large subjects of heredity and environment. Are 
the sins of the father visited upon the children unto the third and 
fourth generations? To a certain extent this is true — especially 
the inheritance of nervous derangements. But while there are 
agencies in the blood of the parents which work injury to their 
germ cells and progeny, environment is capable of originating agen- 
cies benefiting the germ plasm. 

Goiter has been mentioned and is seen in certain localities, due 
to the probable presence of certain living bodies in the water, and 
the absence of iodin. Change of localities may avert the same 
tendencies in the offspring. The children of tuberculous parents 
are very likely to acquire the disease, not through heredity, but 
through exposure to the germs of disease. Change of environment 
will prevent the disease in the children. Comparison of certain 
children reared in this country with their foreign parents will 
show the wonderful effect of environment in overcoming degeneracy 
and degradation. There is indeed a tendency in the young to 
assume a resemblance to a common type of people existing in the 
neighborhood and country, at the expense of inherited charac- 
teristics. 

Environment Versus Heredity: On the one hand the sins of 
the fathers need not necessarily be visited upon the children if 
parents heed the warnings which such sins offer, and instead of 
neglecting the simple laws of health, make an effort to so train 
the bodies of their children that inherent weakness may be overcome. 
On the other hand, the tendency to slight the grave danger of hered- 



318 PERSONAL HYGIENE 

ity and acquired disease in the offspring cannot be too seriously con- 
demned. 

Shall the knowledge that one in every eight persons in cities has 
syphilis; that eighty per cent, of all men in large cities have, or 
have had, gonorrhea; and that this disease leads to fifty per cent, 
of the involuntary childless marriages be denied? Shall such facts 
as are supplied by Fournier — that out of ninety mothers with 
syphilis, fifty had children born dead; thirty-eight bore children 
who soon died, and only two were able to bring into the world chil- 
dren who survived — be made light of ? Ought not parents to realize 
the grave danger which their diseases and habits impose upon their 
offspring? Are the diseased, degenerate, and depraved to be ad- 
mitted as immigrants to our country? 

As regards family inheritance it will usually be found that 
with the aid of an intelligent physician, children may be so reared 
that the predispositions of the parents can in large measure be com- 
bated by proper feeding, environment, hygiene, and education. The 
subject of heredity is a vast, complicated, and still mysterious mat- 
ter. We have herein merely touched upon some of its more salient 
features. With our increasing knowledge of heredity, and especially 
of preventive measures relative to disease, and with the general in- 
terest now aroused in eugenics or race culture, the outlook was never 
more hopeful for the future unborn. 



CHAPTEK V 

HOW TO TAKE TEMPERATURE, PULSE, AND RESPIRATION- 
APPEARANCE OF THE TONGUE— HOW TO GIVE SUBCUTA- 
NEOUS INJECTION AND PASS A CATHETER 

A knowledge of the temperature and rate of the pulse and respi- 
ration is the first essential of diagnosis in every medical case. In 
the following pages the reader is told how these facts may be ascer- 
tained. 

Temperature. — The presence or absence of fever cannot be as- 
certained with certainty by feeling of the skin. Cold hands and 
feet may persist during fever. In fact, during the chill of ordinary 
malaria, when the surface is cold, the teeth are chattering, and the 
patient asks for hot drinks and heavy bedclothing, his temperature 
is at least 102° F. 

To ascertain the real temperature, a clinical self-registering 
thermometer is essential; this may be purchased for seventy-five 
cents. It should be non-magnifying, or a a plain reading" thermome- 
ter, while physicians use a thermometer with a magnifying bulb 
which is difficult to read for those unaccustomed to them. The half- 
minute or one-minute thermometers are more convenient by reason 
of rapidity of registering, but their bulbs are more fragile. 

The thermometer is provided with a scale, showing degrees 
divided into fifths, and generally running from 90° to 110° F. 
An arrow marks 98%°, which is the temperature of normal health. 
A temperature of 100° F., or over, denotes fever. A temperature 
below normal is sometimes seen in health, but unless it persists at 
97° F., or less, it may be considered unimportant. 

To use the thermometer, take it by the upper end, with the 
bulb containing the mercury downward, and swing it back and 
behind you vigorously, or jerk it through the air as if snapping a 

319 



320 TEMPERATURE. PULSE AND RESPIRATION 

whip. This handling must be repeated until the mercury descends 
at least as low as 96° F. The bulb of the instrument is then placed 
under the patient's tongue, and he is instructed not to close the 
teeth but to close the lips tightly around the thermometer and breathe 
through the nose. It must be left in this position for a minute 
more than it is marked : that is. a minute thermometer must be 
held in the mouth two minutes. 

The thermometer may be placed in the armpit, which has first 
been wiped dry. and the skin or flesh of the arm grasped so as to 
allow no air to enter about the thermometer but so as to keep it 
pressed tightly between the arm and side of the chest. 

In the case of children, to avoid riak of breaking, the thermome- 
ter may be inserted into the bowel ( rectum) for an inch or two, the 
patient's feet being held in the air, and the instrument having 
previously been oiled. Although the child may cry, the operation 
is painless. Temperatures taken in the mouth or rectum are most 
accurate. 

In unconscious or violent persons the temperature may be taken 
in the armpit. After removing the thermometer, the scale is read, 
and the instrument washed with soap and cold water, and put into 
its case. Hot water sends the column of mercury up to the end 
of the tube violently, and generally bursts the tube. In the case 
of contagious diseases it is safer to allow the thermometer to stand 
in a solution of two-thirds alcohol and one-third water for five 
minutes, after washing, to avoid conveying disease by the instrument 
to others. Temperatures in fevers are apt to be highest about five 
p. m. and lowest in the early hours after midnight. The hours of 
six and ten a. m.. and four p. m. are good for temperature taking. 



PULSE 

The pulse rate at different ages is as follows : 

At birth 130 to 150 

At 1 month 120 to 140 

At 1 to 6 months 130 

At 6 months to 1 year 120 



THE RESPIRATION OR BREATHING 321 

At 1 to 2 years 110 to 120 

At 2 to 4 years 90 to 110 

At 6 to 10 years 90 to 100 

At 10 to 14 years 80 to 90 

Normal pulse in an adult 72 

The preceding table shows in a general way the number of heart- 
beats in one minute. The pulse may be taken by lightly placing the 
tips of three fingers upon the wrist over the radial artery, which 
is to be felt on the front of the wrist, about half an inch from the 
edge of the thumb side and one inch above the base of the thumb. 
In children it may be felt by placing the fingers on the side of the 
neck under the ear, or on the left breast over the heart itself. 

The pulse in children varies much, and increases on the slightest 
exercise or excitement. It is less rapid during sleep. The usual 
pulse of healthy adults varies considerably; it is rarely as low as 
forty and occasionally runs above eighty. In fever there is ordi- 
narily an increase of eight to ten beats over seventy-five for each 
additional degree of temperature. 



THE RESPIRATION OR BREATHING 

The rapidity of respiration in health per minute is seen in the 
following table: 

From birth to the age of 3 weeks 40 

From 3 weeks to the age of 1 year 30 

During the second year 28 

From the second to the fourth year 25 

From the fourth to the fifteenth year 20 to 25 

In adults 16 to 18 

By a respiration is meant the inspiration (inbreathing) and 
expiration (outbreathing) taken together. In counting the respira- 
tions, place the open palm upon the chest, or in children and men 
upon the abdomen, and count each time the chest or abdomen ex- 
pands, or merely watch the rise of the chest or abdomen. The 
falling movements of the chest or abdomen are not counted. 



322 TEMPEEATUEE, PULSE AND RESPIRATION 

In children the breathing is often very irregular; a child may 
hold his breath and even take several breaths in rapid succession. 
Breathing is more rapid in fevers and diseases of the chest. In fever 
there is an increase of about one respiration to each three or four 
additional heart beats above the natural rate — seventy-two in the 
adult. 

The breathing in grave cases of pneumonia may be as rapid as 
forty in adults, or sixty in babies. The breathing is noisy and crow- 
ing when there is any obstruction in the throat, as in diphtheria or 
croup; noisy and snoring in unconscious persons. (See Disease of 
Throat and Cough.) 



APPEARANCE OF THE TONGUE 

In most cases the appearance of the tongue is not of much im- 
portance, the popular notion to the contrary notwithstanding. Any 
one will have a coated tongue if starving or taking fluids, since the 
coating will form unless kept worn off by eating or chewing. The 
coating is made up largely of cast-off cells. 

When the tongue is coated it often signifies that the digestion 
is disturbed; but there are many persons in comparative health 
whose tongues are habitually coated. A yellow coating frequently 
signifies that the patient's digestion is disordered unless the tongue 
is stained by something in the mouth, as tobacco. Peculiar condi- 
tions of the tongue are characteristic of some disorders, however. 



THE HYPODERMIC SYRINGE 

When a patient is suffering severe pain and is unable to retain 
drugs in the stomach, the injection of morphin under the skin is 
of great advantage. Many other drugs are best given hypodermati- 
cally, but only by a trained nurse or physician. Kapidity and 
certainty of action are also attained by this method. 

A description of the mode of administering drugs under the 



THE HYPODERMIC SYRINGE 323 

skin is here given for the benefit of those who may have the care of 
sick or injured persons and be unable to secure a physician. 

Doctors properly consider it unwise to teach the laity how to 
use a hypodermic syringe because morphin is commonly taken with a 
syringe by habitues. In emergencies, however, knowing how to 
give an injection under the skin may be invaluable. 

A hypodermic syringe usually holds about thirty minims, or 
drops, of water. The medicine used is commonly carried in the 
form of tablets, one of which is dissolved by placing it in a clean 
teaspoon, not more than a quarter filled with pure water. If a 
burning match or alcohol lamp is held for a moment under the spoon 
the water will quickly boil; this not only sterilizes the water, but 
hastens the solution of the tablet. 

The syringe should be washed out by drawing up alcohol or 
boiling water into it a number of times through the needle, and the 
outside of the needle should be wiped with a clean towel wet with 
alcohol, or the needle should be dipped in boiling water. The water 
in which the tablet is dissolved is then drawn up into the syringe, 
including the last drop; then the syringe is held with the needle 
pointing upward, and by pushing in the plunger until the solution 
begins to flow out of the needle, all air is expelled. 

The injection is generally made in the forearm. The skin on 
the front part of the arm, midway between the wrist and elbow, is 
thoroughly cleansed with soap and water and washed with alcohol, if 
at hand. A fold of skin is then picked up between the thumb and 
forefinger of the left hand and pinched firmly to prevent pain from 
the needleprick. Then with the syringe grasped in the right hand, 
the needle is thrust quickly into the fold of skin thus raised. The 
needle should be introduced one-half to one inch, almost parallel with 
the surface of the arm, into the middle of the fold of skin held 
up; not deep into the flesh of the arm. The liquid is slowly in- 
jected and the needle rapidly withdrawn. 

The process is exceedingly simple and without danger, if the 
needle, syringe, and skin of the patient are clean, and air is first 
pushed out of the syringe. The metal syringes with solid plungers 
are likely to prove most satisfactory. 



324 TEMPERATURE, PULSE AND RESPIRATION 

A patient should never attempt to use the hypodermic syringe 
on himself. Many drugs are administered with the hypodermic 
syringe, but morphin 1 is given most often in this way. Not more 
than a quarter of a grain should be injected at a time in adults, 
but if no relief is experienced within half an hour the same 
dose may be repeated. In weak women it is advisable not to give 
more than one-eighth grain at a dose. Morphin is to be shunned 
in troubles where pain is chronic, as the morphin habit is readily 
acquired, and overcome, if at all, only by decided force of will and 
much suffering. 

USE OF THE CATHETER 

In case of retention of urine from various causes it may become 
necessary to use a catheter in order to relieve suffering, if not to 
save life. 

A catheter is a flexible tube, generally of rubber, open at one 
end and often closed with a solid point at the other, but having 
an opening or eye near the closed end through which the urine 
may flow when introduced into the bladder. 

There are two forms of catheter suitable for general use. The 
best is the soft rubber catheter, called also Nelaton's or Jacques', 
and the other is the more rigid, silk-web or English gum catheter. 
The soft-rubber catheter should always be selected in preference 
to the web catheters, unless the soft catheter cannot be passed, when 
the web catheter may be tried, but the stylet or wire, which is some- 
times inserted in this catheter when bought, must first be with- 
drawn. If the catheter were introduced by unskillful hands, with the 
wire in it, damage to the organ might easily result. 

The soft-rubber catheter should be boiled in water for five min- 
utes before it is used, in order to kill any germs which may be 
attached to it. This is also the best way of preparing the silk-web 
catheters, but only the most expensive and finest make will stand 
boiling many times. 

After using, catheters should be thoroughly washed in warm 

1 Morphin is only sold on a doctor 's prescription and is a dangerous drug. 



USE OF THE CATHETER 325 

water and soap, and a stream of clean hot water be allowed to 
run through them. They should be kept wrapped in a clean towel 
or in a long case made for the purpose, and not coiled. 

The solid point of the catheter containing the eye is the end 
to introduce into the urinary passage. The parts about the urinary 
passage in the male or female must be thoroughly washed with 
soap and water. The hands of the operator must be scrupulously 
clean. After thoroughly washing the hands it is safer to also wear 
surgeon's rubber gloves which have been boiled five minutes. The 
gloves should remain in the water until it is sufficiently cool and 
then the gloves should be partially filled with water, to facilitate 
putting them on. A glove on the right hand alone, which touches 
the catheter, will do. The object is to avoid getting germs on the 
catheter from the bare hand. 

The catheter, after boiling, must not come in contact with any- 
thing except the urinary passage and the clean hands of the opera- 
tor. A towel, which has previously been boiled, should be spread 
about the sexual organs of the patient to prevent the catheter from 
touching the skin or the bed. 

The patient should lie down with the shoulders slightly raised 
and the thighs bent so that the knees are in the air. It is im- 
portant that the patient should be relaxed and keep the mouth open 
while the instrument is being introduced. The penis of the male 
is grasped by the left hand of the operator, who stretches it upward 
toward the middle of the belly and separates the lips of the urinary 
•passages with the forefinger and thumb of the same hand, while 
the catheter, which has been dipped into liquid vaselin or glycerin 
in a clean glass, is passed slowly and gently into the urinary pas- 
sage. Or, as more convenient lubricants, we may squeeze some 
of the contents from a collapsible tube containing sterile vaselin, 
or the lubricant sold as K-Y, on the catheter before it is introduced. 
It is impossible to infect a patient in using the soft-rubber catheter 
if proper cleanliness is observed. 

When the catheter enters the bladder the urine will begin to 
flow from the outside end of the catheter into a vessel provided for 
the purpose. After the bladder is emptied the catheter is with- 



326 TEMPERATURE, PULSE AND RESPIRATION 

drawn while pinching together its outer end to prevent the urine 
which is contained in it from leaking out. In females, the urinary 
passage begins in a little depression, easily found if the outer folds 
are separated, directly above the entrance of the vagina. Catheter- 
izing a woman is very easy if the entrance to the passage is seen. 
In case catheterizing is difficult in the male and the instrument 
sticks at some point, it must be withdrawn for a little way and 
then pushed in again, or a different size must be used. If this is 
not successful the more rigid silk-web catheter may be tried, but no 
metal instrument should ever be introduced by an unskilled person. 

The average size of catheter for the average patient, male or 
female, is No. 15 French, 8 English, or 10 American, according 
to which scale is used. A short glass catheter is often used for 
women, but the soft-rubber catheter is by far the best instrument. 
If voluntary passage of urine is impossible the catheter should be 
used about once in eight hours. 

The chief danger in using catheters is the introduction of 
germs into the bladder causing inflammation of that organ. Only 
absolute cleanliness will prevent such a result. 



CHAPTEK VI 
DISEASES OF CHILDKEN 

Inflammation of the breasts. Retention of urine. Phimosis. Hemorrhage 
in the newborn. Prolapse of the bowel. Wasting. Soreness, swelling, 
and pain in legs. Eever. Enlarged glands. Rickets. Holding the breath. 
Chorea. Pott's disease of the spine. Lateral spinal curvature. Hip 
disease. Bow-legs. Knock-knees. Weak and flat feet. 

The larger number of diseases of children are common to adults 
as well, and may be found in other parts of the book by consulting 
the index. Special mention has been made of any peculiarities of 
these diseases which may occur in children. 



INFLAMMATION OF THE BREAST OF THE NEWBORN 

This is not uncommon. The breasts of either girl or boy babies 
become swollen and tender, and a few drops of thin milk may 
exude from them. Ordinarily the child's temperature is not above 
normal, nor is the appetite disturbed, and these cases subside with- 
out causing any trouble. 

The breasts should be gently and thoroughly washed with soap 
and warm water, and then covered with a few layers of cheese- 
cloth, which has been spread with a mixture of one part ichthyol 
and three parts zinc oxid ointment, and then with oil silk and a 
flannel band about the chest, with shoulder straps to keep it in 
place. Wet dressings are not advised. Attempts at massage and 
squeezing out the milk are sometimes the cause of abscess. 

If abscess of the breast results there are increasing inflamma- 
tion and redness, formation of matter (pus) and fever, loss of ap- 

327 



328 DISEASES OF CHILDREN 

petite, and general disturbance. Such a case must of course be 
referred to the surgeon at the earliest moment for incision. 



RETENTION AND PAINFUL PASSAGE OF URINE 

The baby may pass no urine for twenty-four hours after it is 
born, and yet there may be no cause for worry. If no urine is 
passed in the first twelve hours, it is well to put the baby in a warm 
bath, and if this does not lead to a passage of urine a doctor should 
be consulted, as there may be some deformity or obstruction. 

Very rarely there is no opening for escape of excrement from 
the bowels, and this is first brought to the attention by failure of 
the child to have a bowel movement. A surgeon must be summoned 
at once to remedy this condition. 

No urine is passed for many hours after a bad attack of colic 
in some cases, but this condition may be relieved by the warm bath. 

Pain during the passage of urine may be observed when the 
urine is too concentrated and stains the diaper with a reddish or 
yellowish substance. Giving the baby an abundance of water will 
relieve this condition. 



SMALL OPENING IN THE FORESKIN FOR PASSAGE OF 

URINE 

(Phimosis) 

This is seen in the newborn boy baby as a natural condition. 
The opening is not only small as a pinhole, but the foreskin cannot 
be withdrawn so as to expose the head of the penis. Naturally, this 
state changes as the child grows, but if it does not, and the foreskin 
remains attached to the parts beneath and cannot be moved freely 
over the penis, and if the opening for the passage of urine is very 
small, several bad results are apt to follow. 

The end of the penis is likely to become sore, red. and swollen, 
and the passage of urine painful. Some discharge may occur. The 



BLEEDING OF CORD AND SORENESS OF NAVEL 329 

irritation leads to rubbing of the parts, and the bad habit of mas- 
turbation often thus begins. Bed-wetting is a common sequence of 
the irritation. Prolapse of the bowel or rupture may be caused 
by straining to pass water. Various nervous disorders owe their 
beginning not infrequently to a narrow foreskin, such as convulsions, 
St. Vitus's dance, fever, general ill health and nervousness. 

It is the custom in many hospitals and in private practice 
for the nurse to daily draw back the foreskin of the infant, until 
by the end of the fourth week it may be drawn back over the head 
of the penis, and the natural greasy secretion washed off. This is 
a good way to teach the child self-abuse and occasionally the fore- 
skin cannot be returned, on account of swelling of the organ, so 
that it must be cut. Stretching of the foreskin is also advised in 
place of circumcision, but the original narrowing of the entrance 
is sometimes made worse by this operation. 

The writer is a firm believer in circumcision for every male 
child within a few weeks of birth. It does away with the necessity 
of the nurse manipulating the organ in order to cleanse it and, in 
preventing any sort of irritation, it is the best preventive of mas- 
turbation. 

Treatment. — This consists in circumcision, that is, cutting off 
circularly a portion of the end of the foreskin. Parents should 
consult a physician when there is any suggestion of trouble such 
as has been described. 



BLEEDING OF THE CORD AND SORENESS OP THE NAVEL 
IN THE NEWBORN 

Bleeding of the cord occurring soon after birth must be stopped 
immediately by tying a soft string tightly about it, as far from 
the belly as the string will remain without slipping off. Slight 
oozing after the cord has dropped off is usually of no consequence. 

There is, however, a rare form of bleeding from the cord ap- 
pearing within the first few days after birth which nothing has 
hitherto been able to stop. Bleeding may also occur at the same 



330 DISEASES OF CHILDEEN 

time from the bowels, nose, mouth, and other parts. It is a peculiar 
disease of the blood and has heretofore been very generally fatal. 
Xow it is almost invariably cured by the injection of the blood of 
one of the parents, brothers or sisters. Sometimes the cord will be- 
come soft and offensive, and when it comes away will leave a large 
sore behind it. There may be a little pea-shaped swelling in the sore 
which discharges matter. 

Treatment. — In the absence of a physician the cord or sore 
should be washed three times daily with boric acid solution (one 
teaspoonful to one-half pint of warm water) and clean absorbent 
cotton, and then dusted with a mixture of two drachms each of 
boric acid, starch, and zinc oxid, and six grains of salicylic acid, 
and covered with clean gauze or soft cotton. 



PROLAPSE OF THE BOWEL 

This condition is brought about by great or constant straining 
caused by diarrhea, constipation, a narrow foreskin with difficult 
urination, worms, whooping-cough, overeating, with too frequent 
large movements of the bowels, etc. A protrusion of the bowel 
from one-half inch to several inches long is to be seen. Ordinarily 
it presents the appearance of a dark-red or purplish, puckered 
ring at the point of the opening of the bowel which goes back or 
can be pushed back into place. It reappears, however, whenever 
there is much straining, as during a passage from the bowels. There 
is generally little pain connected with the trouble, unless the pro- 
trusion is large, when — if it remains out for a considerable time — 
it becomes very painful, inflamed, and may ultimately die and 
cause the death of the patient. 

Treatment. — This consists in removing the causes if possible. 
In many cases keeping the feces soft with albolene (see Constipa- 
tion) and refusing the child all food between meals, with the use 
of cold sponging, may bring about a cure. 

The first thing to do is lay the child flat on his face, cleanse 
the protrusion with warm water, grease it with vaselin, and push 



WASTING 331 

it back. The injection of a little ice water into the bowel (a 
cupful three times daily) will have a most beneficial effect. 

To prevent a return of the trouble the child should be required 
to have a movement while lying on its back on a diaper or bedpan, 
or by employing a board, having a hole only three inches in diame- 
ter, which is placed over a chamber vessel for the child to sit upon 
when the bowels move. A baby must not be allowed to sit upon a 
vessel more than five minutes at a time ; there is no more pernicious 
habit in causing prolapse of the bowel than a long session at this 
occupation. Special apparatus and operations are necessary to cure 
chronic or large protrusions of the bowel. 



WASTING 

(Marasmus) 

This is a condition of infants seen more often during the first 
year, and is due to various causes. More frequently it occurs in 
bottle-fed infants, who receive improper food, as rich milk, patent 
foods, cereals, or even vegetables, meat, or bread, during the first 
months of life. The child is starved because it cannot digest such 
food. The usual history has been that the baby would not take 
mother's milk, was then given cow's milk which was too strong 
or too large in amount, and this not agreeing with him, experiments 
in various patent foods were tried. The result is that at the age 
of six months the baby weighs less than at birth. Such babies either 
are born with an inability to digest cow's milk or have grown into 
this state through improper feeding. 

The skin is sallow, wrinkled, and hangs in folds. The eyes are 
sunken, and the lips thin and pale — the patient looks like a little 
old man. There are sore patches about the buttocks and inner 
surface of the thighs; the appetite is often voracious; the tongue is 
heavily coated and dry ; colic is frequent, and the passages are com- 
posed of curds or little lumps covered with greenish slime. Some- 
times diarrhea and vomiting are present. The baby cries much or 
dozes a great deal; it often sucks its clawlike hands until they are 



332 DISEASES OF CHILDREN 

raw; rolling and squinting of the eyes and spasms are common in 
bad cases. The temperature is generally below normal. 

Milder forms of wasting are seen in breast-fed infants, when the 
milk is too poor and insufficient to nourish the child, or too rich 
to be digested. Indigestion and lack of cleanliness in the care of 
the bottles and nipples also favor marasmus. 

It is often seen in babies born with syphilis, but in them are 
signs of inherited syphilis, as continual snuffles, hoarse cry, moist 
patches about the mouth and the rectum. Cracks about the mouth 
and a flattened bridge of the nose are also common to this condition. 
Tuberculosis may likewise cause wasting in infants, but in this 
disease there is a temperature of 100° to 101° F. or more, and cough. 

Treatment. —The essential treatment consists in obtaining a wet- 
nurse for the infant. Nothing else will take her place. 

After being fed on a bottle it may be difficult to get the infant 
to nurse. By waiting an hour or two after the usual feeding time, 
by feeding the baby in the dark, and by placing a little sugar and 
milk on the nipple, the child may be induced to nurse. Giving 
barley water before meals, if the baby is inclined to get too much 
milk, or after nursing, if the child gets too little, will make the 
milk more digestible. Weighing the baby before and after nursing 
will show the amount of milk taken. 

An outdoor life is important and great heat should be avoided. 
Rubbing sweet oil over the body, after sponging with warm water 
night and morning, will be found beneficial. 

If a wet-nurse is an impossibility, feeding with barley water 
and later with small quantities of milk or cream added to barley 
and milk-sugar water is advisable, but must be directed by a doctor. 
The greatest care and experience are required in such cases, but 
no patient is too sick to recover. 

SORENESS, SWELLING AND PAIN IN THE LEGS— GROWING 

PAINS 

When infants cry out if they are moved, it is suggestive of 
scurvy or influenza (if fever). Older children suffering from pains 



FEVER 333 

in the limbs — often, through ignorance, called "growing pains" — 
are victims of muscular or acute rheumatism in many cases. En- 
largement and disease of the tonsils produce growing pains from 
general poisoning of the system, and these may be cured by removal 
of the tonsils. 

Kerley describes a condition, not uncommon in children, in which 
growing pains, enlarged tonsils, periodic attacks of vomiting, and a 
tendency to croup, colds, eczema, and hives are observed. 

He states this may be cured by giving children only skim milk, 
or buttermilk, and avoiding the yolk of egg and sugar. The white 
of egg, cereals, vegetables, cooked fruits, and a moderate amount 
of meat, poultry, and fish are allowed. In place of sugar a little 
saccharin may be used. A daily bath in warm water should be given 
at night and then cool (and gradually cold) water should be dashed 
over the body while the child stands in warm water. 

FEVER 

Fever is only a symptom of disease, but until it is known to 
what it is due the same general treatment may be pursued in all 
cases. 

The first thing to do is to take the temperature with a ther- 
mometer, as described in the preceding chapter. This is the only 
way to be sure of either the presence or degree of fever — no other 
signs are conclusive. A temperature of less than 101° E. might be 
called a slight fever; between that point and 103°, a moderate fever. 
High fevers are much more common in children, and are not of so 
serious import as in adults, unless continued. A temperature of a 
hundred or over always means some sort of a physical disorder; no 
single test is so reliable in determining whether a child is sick or not. 

Fevers lasting for a few days are not so harmful as commonly 
fancied, unless the temperature is high. Eever is nature's method of 
combating the cause in most cases, and moderate fever, unless it con- 
tinues for many days, need not cause anxiety, so far as the increased 
temperature itself is concerned. 

High fever — especially in children — should be reduced, since 



334 DISEASES OF CHILDKEN 

headache, delirium, and, in infants, convulsions are not uncommon. 
A child with fever should be immediately isolated in a room by him- 
self until it is known that the disease is not contagious, as the eruptive 
diseases of childhood, tonsillitis, grip, infantile paralysis, and diph- 
theria are often first made apparent through fever. 

Treatment. — When fever is high, cold applications should be kept 
on the head. This is best secured by the rubber cap made to contain 
cracked ice, but if this cannot be obtained, a single thickness of soft 
cotton wrung out of ice water should be placed on the forehead and 
frequently moistened with ice water as it evaporates. The application 
of the cloth or ice cap ought to be continued as long as the fever re- 
mains high. Cold water may be applied by sponging the entire sur- 
face of the body while a hot water bottle is kept at the feet. The 
higher the fever the cooler the water should be. Ordinarily water at 
about 70° F. may be used. The sponging should be continued for 
five or ten minutes, the surface is then thoroughly dried, and the 
patient covered moderately. Heavy covering is always bad in fevers. 
Sponging may be repeated every two hours if necessary, but should 
not be employed unless in a warm room — 70° F. or over. When 
there is an eruption, sponging with lukewarm water is advisable, in 
a warm room. It is not necessary to reduce the temperature below 
102° F. in most cases. 

The diet in fever must be liquid; infants on milk diet should 
have the mixture diluted one-third to one-half with water. Milk, 
broths, albumen water, and thin cereals constitute the best diet, as 
a rule. An abundance of cool water may be allowed in fevers, but 
a little at a time and frequently, is the rule. Rest in bed is impera- 
tive. Moving the bowels is also good practice in these cases: castor 
oil or calomel are commonly used, or other suitable cathartic may 
be given. If vomiting is present, the giving of any food for twelve 
to twenty-four hours should be avoided. 



ENLARGED AND TUBERCULOUS GLANDS 335 



ENLARGED GLANDS OF THE NECK AND OTHER PARTS- 
TUBERCULOUS GLANDS— SCROFULA 

Glands are natural structures, but are not usually perceptible to 
sight or touch unless enlarged by disease. There are some eight hun- 
dred glands in the body and, of these, three hundred are in the neck 
alone and form a sort of collar, although four-fifths of them are on 
either side of the neck behind the lower jaw. 

Glands are part of a drainage system (lymphatic system) con- 
sisting of fine tubes, much finer than the blood vessels, which drain the 
tissues all over the body and finally empty into the blood. Glands 
occur in the course of the lymphatic system, acting as traps do in 
household drainage systems, and in the body to catch germs, and the 
poisons they produce, and prevent these from passing along into the 
blood and entire body. When the glands are diseased, as in enlarged 
tonsils, the germs may pass directly through the tonsils and become 
caught in the glands of the neck. 

Germs gain entrance to glands through wounds, sores, abrasions, 
and inflammations in various parts of the body. Enlarged glands 
of the neck are more common than elsewhere because inflammation 
about the throat, nose, and mouth is so frequent. The glands in the 
neck drain all parts of the head, the face, scalp, inside of the nose, 
mouth, and upper part of the throat. Then all the glands under and 
behind the jaw and in the back of the neck drain into the deep glands 
in the side of the neck ; hence the frequency of swollen glands in this 
location. 

Enlarged glands are seen and felt usually as movable lumps under 
the skin, and may or may not be tender. In the neck, as has been 
indicated, they may be found below or behind the jaw, below the scalp 
at the back of the neck, and along the sides of the neck. Enlarged 
glands in the armpits arise from inflammation in the hands, arms, 
or chest ; enlarged glands in the groins (where the upper and inner 
part of the thighs join the body) are caused by inflammation in any 
part of the legs, or external sexual organs. 

In the neck enlarged glands are due to inflammation of the tonsils, 



336 DISEASES OF CHILDREN 

adenoids, sore mouth, sore tongue, bad teeth, to abscess of the ear, and 
to the presence of lice and eczema on the scalp. Sore throat from 
any cause, particularly tonsillitis, diphtheria, and that common to the 
acute eruptive diseases, as measles, German measles, and scarlet 
fever, are the most common causes of enlarged glands. 

But swollen glands from all these causes are temporarily swollen 
for a few days or weeks and then disappear. Enlarged glands occur 
more frequently in children between the ages of four and ten, and 
we will find them existing in a majority of children during this 
period. 

In cases where these glands have been continuously enlarged for 
months or years there is usually also an infection with tuberculosis. 
In other words these glands have perhaps become enlarged through 
the causes mentioned above, and secondarily infected with tubercu- 
losis, because, being already diseased, they afford an inviting field for 
further disease. There is no way of telling how badly such glands 
are infected with tuberculosis, but it is safe to regard chronically 
swollen glands in children as being tuberculous or scrofulous, to use 
the old term. 

Swollen glands arising from diseases with sore throat appear 
rapidly, are often quite tender, but rarely form abscess, and vanish 
spontaneously. Tuberculous glands develop slowly; one or more 
lumps but slightly tender appear in the neck and tend to gradually 
increase in size and number and, after months or years, may become 
red and sore, soften, and form abscesses and leave a chronic oozing 
hole in the neck. 

Tuberculous glands are not necessarily incurable, in fact most 
of them are cured by proper treatment without operation. Diseased 
tonsils allow the tuberculosis germs to penetrate through them into 
the glands in the neck, the germs entering the mouth in dust, on 
various objects sucked by children, and in food, especially milk from 
tuberculous cows. 

Treatment. — The first object in treating glandular enlargements 
in the neck in children is to remove sources of infection in the 
throat — and these are chiefly diseased tonsils and adenoids. Atten- 
tion should also be given to decayed teeth, and the condition of the 



ENLARGED AND TUBERCULOUS GLANDS 337 

nose and mouth. Any diseases in these parts must be remedied. 

Then the child should be given an outdoor life in the country, 
if possible, and should receive especially nourishing food, as pas- 
teurized or certified milk, cream, eggs, meat, oatmeal, purees of dried 
peas or beans. The syrup of iodid of iron is often of value, more par- 
ticularly if the child is anemic. This is given in a dose of fifteen 
drops in water three times daily after meals to children over five. 
Iodin petrogen may be rubbed night and morning on the glands for 
five minutes, unless they are sore or become so, when the treatment 
should be stopped for a few days. The use of the x-rays and in- 
jections of tuberculin have been successful in the hands of some 
experts. 

There has been much discussion in the profession as to the ad- 
visability of removing glands in the neck in children, by the knife. 
Many well-recognized children's specialists advise this. But the lead- 
ing surgeons to-day do not advise surgery on glands in children until 
they have been given the treatment recommended above. 

It will be found that the majority of ■ children with tuberculous 
glands will wholly recover, and the glands disappear, with removal 
of enlarged tonsils and adenoids, combined with life in the open 
and nourishing diet. 

If, however, the enlarged glands persist and grow in size and 
number, or if the glands soften and become filled with cheesy matter 
or pus, then the surgeon must step in. The proper operation com- 
prehends the removal of all the glandular tissue on one side of the 
neck from the ear to the collar bone, through one long incision. 

Until recently surgeons removed only a portion of the glands, and 
more soon appeared, and it was commonly said "the glands have 
grown again." This, like the recurrence of tonsils after operation, 
means simply that the glands were only partially and imperfectly 
removed. Glands do not return after complete removal any more 
than a leg. When not wholly removed the remaining glandular tissue 
may become diseased and present the appearance of new glandular 
growths. The scar too is very slight and unnoticeable by the modern 
operation. 

Tuberculous glands often occur in the chest in children and are 



338 DISEASES OE CHILDREN 

a common cause of tuberculosis in them. The glands in the neck 
are not, however, directly connected with those in the chest, as 
formerly thought. 

RICKETS 

Rickets is a common disease of infants (occurring in fifty to 
eighty per cent, of babies) between the ages of three months and two 
years, among the less favored classes in large cities. 

It is essentially a disease caused by improper diet — usually in 
infants fed on sterilized, condensed milk, proprietary foods, or on 
cow's milk not properly diluted to suit the digestion. Eickets may 
be found in children when nursing from the breast, but in these 
cases the milk is found to be deficient in composition — chiefly in pro- 
teid, and often in fat. "When an infant nurses from the breast for 
more than nine months the milk will usually be found deficient in 
quality. Babies who are fed only on milk when over a year old, or 
largely starchy proprietary foods, are prone to rickets. Xo infant 
who receives a well balanced diet and assimilates it will develop 
rickets. 

Eickets, like pellagra, is apparently due to a diet deficient in pro- 
teids (small vitamines) and perhaps fats, and there is evidence 
to show that sufficient phosphorus is also lacking, as in beriberi 
and other nutritional disorders. In rickets there is absorption of 
bone already formed, and impairment in the bone-making functions, 
so that lime and salts are not readily assimilated. 

Xo single symptom will enable us to diagnose rickets : only the 
general picture is characteristic. The infant is pale and puny, with 
soft, flabby flesh. He seems sore on being handled, and often has a 
temperature of 100°-101° F. at night. The head is large for the 
body and feet, teething is much delayed, and the soft spot in the top of 
the skull may not close until the third or fourth, year. Normally the 
first teeth (the two lower front teeth) appear from the sixth to the 
eighth month, and the soft area in the top of the head is closed with 
bone by the twentieth month. The baby is fretful, subject to colds, 
does not sleep well, and sweats about the head and neck at night. 



EICKETS 339 

The chest is often deformed so that the breast bone projects 
(pigeon-breasted), there may be a horizontal groove about the sides 
of the chest, and the spine may be bowed. There is often a vertical 
row of little lumps on the ribs on either side of the breast bone. 
The child is pot-bellied and bow-legged, less often knock-kneed. 
There is a tendency to attacks in which the child loses its breath and 
gets black in the face, and convulsions are not infrequent. The 
normal child's head increases in circumference about four inches 
the first year, three inches the first six months, and but one inch 
the second year. When the growth is much greater the case is apt 
to be one of hydrocephalus rather than rickets. 

Treatment. — If the infant is being fed on cow's milk it may be 
too rich and should be properly diluted. Orange juice should be 
given with pasteurized milk (p. 255). Artificial foods and con- 
densed milk must be discontinued. After the first year meat juice, 
scraped beef, oatmeal, boiled egg, and butter should be added to the 
milk diet. Pure cod-liver oil in doses of ten to thirty drops at six 
months, or from six to twenty months, twenty to sixty drops (or a 
teaspoonful), given three times daily after meals, is most beneficial. 

The baby should be bathed in a brine bath at night, consisting 
of water at 95° F. to which is added a level tablespoonful of salt 
to the gallon. Following this two teaspoonfuls of lard or cocoa butter 
should be thoroughly rubbed in the skin for ten minutes. 

If there is deformity in the legs or back the child should be kept 
on his back most of the time, not being allowed to stand until at 
least three or four months of treatment have elapsed. There should 
be plenty of fresh air in the room. 

Too much sugar, bread, potato, and starch food generally favor 
rickets. After the second year purees of dried peas and beans are 
advisable, and plenty of butter. 

The child should be outdoors in the carriage whenever the weather 
permits. 

Braces for bow-legs are of little service, but correction is done 
by operation after the third year. Curvature of the spine is best 
treated by rest in bed, massage, and exercise, not by braces, plaster 
jackets, etc. 



340 DISEASES OF CHILDREN 

SPASM OF THE LARYNX— " HOLDING THE BREATH" 

This rather rare nervous disorder often occurs in children of six 
to eighteen months (occasionally later) with malnutrition and rickets. 
At other times the cause cannot be discovered. 

The attacks are most apt to come on if the child is scolded or 
stopped from doing something, after fright or crying, also after 
swallowing or exposure to draughts. The condition is due to sudden 
spasm of the muscles of the throat so that the air passage is tempo- 
rarily closed. 

An attack usually comes on during crying. There is a struggle 
for breath, the child makes whistling noises, the face becomes red, 
then bluish, and the breathing suddenly stops. Just when suffoca- 
tion seems imminent, the breath is drawn in — with a crowing sound 
in many cases — and the attack is over with the passing away of the 
spasm in the throat. The whole attack is ordinarily a matter of 
seconds. Similar attacks are apt to occur many times during the 
day. 

In severe attacks the child appears to fall into a faint and is 
wholly relaxed and unconscious for some seconds to a minute or 
two, or convulsions may appear. These are the dangerous cases, 
and death has been known to occur. The lightest cases are those in 
which children with rickets awake during the night with difficult 
breathing, causing a crowing sound when they draw in their breath. 
Taking the cases as a whole, recovery is the rule and danger is slight. 
Usually the attacks continue at widely varying intervals for several 
weeks. 

The disorder is more frequent in England than the United States. 
It is not associated with either cough or hoarseness. 

Treatment. — In mild attacks hold the child upside down and 
slap him on the back. If he does not immediately recover, dip him 
alternately in hot and cold water. A physician should be sent for at 
the earliest moment because it may be necessary to put a tube in the 
throat or to do artificial respiration to prevent suffocation. 

These attacks, like convulsions, are due to an insufficient develop- 



CHOREA 341 

merit of the brain centers which resist the effects of nerve irritation. 
The aftertreatment is similar to that advised for convulsions. 

All sources of irritation should be removed, as adenoids, worms, 
constipation, and tight foreskin. Inflamed gums may require lanc- 
ing in difficult teething. Patients must be kept quiet and not be sub- 
jected to loud talking, rough playing, or receive too much attention 
from adults. The diet and general care should be that advised above 
in the treatment of rickets. 

CHOREA 

(St. Vitus s Dance) 

This is a nervous disorder chiefly affecting children between four 
and sixteen ; it occasionally attacks pregnant women. It is twice as 
frequent in girls as in boys. 

Causes. — Grief, fright, a severe scolding, overwork at school, 
eyestrain, anemia, or malnutrition are among the exciting causes. A 
strong tendency to the disease exists in certain families. There is 
a close relationship between chorea and rheumatism. Rheumatism 
occurs in about fifty per cent, of cases. It is thought that the same 
germ (and its poison) which causes the changes in the joints and 
heart in rheumatism influences the brain to produce chorea. Acute 
rheumatism sometimes begins with chorea, and at other times chorea 
occurs during the course of acute rheumatism or follows it, at longer 
or shorter intervals. The great danger in chorea, as in rheumatic 
fever, lies in the probability of being followed by chronic valvular 
disease of the heart, which has been found in fifty per cent, of pa- 
tients who had suffered from chorea. 

Symptoms. — Chorea generally begins gradually. The child be- 
comes fidgety and cannot sit still, cries easily, and often has night 
terrors, pains in the limbs, stomach ache and other digestive disturb- 
ances. The patient is apt to be misjudged as being willful, and 
after a time appears awkward, and frequently trips and falls in walk- 
ing, upsets or drops things at the table, or has an unusual hesitancy 
in speech. 

Then the characteristic feature of chorea begins in twitching of 



342 DISEASES OF CHILDEEN 

the muscles of the hands, arms, and face, and — to less extent — of 
the legs. Sometimes only one side of the body is affected. The face 
is wrinkled and contorted with grimaces, and the arms are jerked 
about in the most irregular fashion, which cannot be prevented by the 
patient. The movements may be almost continuous, or with long 
intervals of quiet, and are much worse when the patient is nervous 
or tired. The limb affected is much weaker than its fellow, and there 
is a loss of power to direct its use. Thus the child cannot place the 
tip of the forefinger of the affected arm quickly on the tip of his 
nose, and the hand-grasp is weaker than that of the sound arm. 

In severe cases the patient is unable to walk, talk, feed, or undress 
himself without assistance — so violent are the movements. The 
twitching of muscular contractions cannot be stopped by control of the 
will, while habit spasm (in which the child acquires the habit of 
grimacing or jerking the head to one side, especially when tired or 
excited) may be arrested by exercise of the will. The spasms cease 
in sleep. 

The disease tends to run a somewhat uncertain course of six 
weeks to six months, with recovery, under proper treatment. Chronic 
heart disease may persist. A return of the disease is not uncommon 
— more often in the spring. A varying degree of mental weakness 
accompanies chorea, from a state of deficient memory, fretfulness, 
irritability, and incapacity for brain work to a condition of tempo- 
rary insanity in rare cases. 

Treatment. — The child must be taken away from school to avoid 
all mental application as well as ridicule and excitement. He should 
not be subject to punishment for the movements, grimaces, or drop- 
ping things. 

Rest in bed from one to four weeks is required for severe cases 
when the twitching interferes with walking and eating. Avoidance 
of physical and mental fatigue and excitement is essential. In the 
milder cases the child should live outdoors with a nurse or parent, 
and not play with other children. Rest in bed for part of the day is 
advisable. Horseback exercise, shooting at targets, croquet, and out- 
door exercises not requiring violent exertion and free from excite- 
ment, are desirable. In the case of patients confined to bed a gradual 



POTT'S DISEASE 343 

return to ordinary life should be required, getting up for a longer 
time each day. 

The drug treatment consists in the use of sodium salicylate and 
baking soda, as advised in acute rheumatism. (Part III, Chapter 
VI.) 

Diseased tonsils should be removed. Candy must be forbidden, 
and meat taken but once every other day. As relapses are frequent 
the patient should be under the constant supervision of a physician. 



POTT'S DISEASE 

(Angular Curvature of the Spine — Tuberculosis of the Spine) 

Causes. — This is a disease caused by softening and destruction 
of a portion of the vertebrae (bones of the spine) due to the germs 
of tuberculosis. It is a tuberculosis of bone. There is often the his- 
tory of a blow on the spine, or of a fall, and the disease more fre- 
quently follows one of the diseases of childhood, as measles, whoop- 
ing-cough, scarlet fever, etc. Pott's disease is thought to spread 
from tuberculosis of the glands in the chest or belly. 

Course of Disease. — It begins more frequently in children be- 
tween the ages of three and five, although often at other periods. If 
it goes on without early treatment it causes death eventually in about 
one-fifth of all cases, or leads to deformity of the spine, or humpback, 
and many other conditions, as abscesses in the groins and back, 
paralysis, etc. The seat of the disease is more often in the upper 
two-thirds of the back. 

If, on the other hand, treatment is begun at the onset before 
there is any (or but slight) deformity, the disease is frequently 
cured completely. It is of the chiefest importance then for parents 
to recognize spinal disease at the earliest moment. 

Symptoms. — The disease begins slowly. Before any definite 
symptoms present themselves the child appears fretful, lies on, the 
floor, and is loath to stand or play, and often has a cough or pain % 
the abdomen. The chief symptoms are pain, stiffness of the back, 
awkwardness in moving, weakness, and deformity. Pain is not felt 



344 DISEASES OF CHILDREN 

in the back usually, except when jarred, although at night the 
child often cries out in his sleep, owing to unconscious movements. 
Neither is tenderness on pressing the spine common, but chronic 
pain is felt more often in both sides of the belly, as stomach ache 
and colic. 

Stiffness of the back is a very important sign. The child does 
not bend his back freely, but carries himself stiffly, and when he 
stoops to pick up anything, squats down by bending the legs at the 
knees and hips and leans forward with his hands on his thighs to aid 
in straightening up. Weakness is shown by the child's dislike to 
stand or walk. He tries to hold on to something for support, tot- 
ters about on his toes, and falls frequently. He walks with a shuf- 
fling gait to avoid jars, and with squared shoulders and head thrown 
back. 

To test for stiffness in the neck, get the child to sit with his 
back against a support and to move the head far to one side and then 
to the other, and to nod the head far forward and backward. To test 
for disease in the upper part of the neck mark the bony prominences 
all the way down the spine, with the child on his face. If two 
or more marks are especially separated from one another, in standing, 
it shows trouble in that part. To test for diseases in the lower part 
of the back lift the child, lying naked on his belly in bed, by his 
ankles. If there is stiffness in this part it will be shown by the 
chest being lifted from the bed and the small of the back not becom- 
ing more hollow. 

Deformity is usually the first sign which calls attention to the 
real nature of the disease (unless the parents are awake to the possi- 
bility of the trouble) and this is unfortunate because it is essential 
that a physician should treat the child at the earliest possible mo- 
ment. The deformity is seen as a knuckle-like projection in some 
part of the back, and is made much more noticeable by bending the 
back. Occasionally there is a curvature of the back caused by rickets, 
but in this case the spine is bowed outward through a great part of 
its length, and the deformity disappears with the patient lying on 
his face. In rickets there are other signs, as enlargements of the 
wrists and beadlike swellings on the ribs. 



LATERAL CURVATURE 345 

The temperature in Pott's disease, or tuberculosis of the spine, 
is apt to range from 99 1 /2° to 100° F. If the spine in the neck is 
diseased, the shoulders are apt to be held high and there is often a 
chronic stiff neck, while if in the lower part of the back the child is 
apt to lean forward with the hands resting on the thigh. 

In adults, Pott's disease begins with headache, backache, and a 
belt-like pain about the abdomen, or paralysis in the lower limbs. 

Treatment. — The treatment consists in absolute rest in bed, or 
in transporting the patient about on a canvas stretcher in the early 
stages of the disease, or in the use of supports for the back, or in an 
ingenious operation (Albee's) for splinting the back by inserting a 
piece of bone from the leg into a lengthwise cleft in the spine. 

There is great need for the parent to be able to even suspect the 
disease in its early stage so as to call the attention of a physician 
to it at this time — hence the rather elaborate description of early 
signs and symptoms. 



LATERAL CURVATURE 

Causes. — This disorder differs entirely from the last described. 
Lateral curvature of the spine is a deformity of the body due to a 
bending or bowing of the spine to one side, so that instead of being 
straight it assumes somewhat the shape of the letter S. Not only is 
the spine bent to one side, but owing to certain causes it is turned 
to some extent on its axis. 

In the beginning, this distortion of the spinal column is not usually 
brought about by disease of the spine itself although sometimes in 
children with rickets the softer bone favors the deformity — but 
arises from causes which tend to pull, more or less constantly, the 
spine out of line, and, occurring at an early age when the spinal 
structures are very pliable, permanent distortion results with gradual 
changes in structure of the bones of the spine (vertebrae) in conse- 
quence. It is very important, then, that this condition be discovered 
before actual structural changes occur, because the disease may be 
overcome, and incurable and lasting deformity can be prevented. 



346 



DISEASE - : CHILLI::::: 



Among the causes are all sorts of circumstances leading to faulting 
i :ns of the body, as improper arrangement of school desks and 
chairs of had shape ; carrying heavy weights constantly in one hand 
or arm, as children carrying books and babies; certain occupations, 
effects of clothing, diseases, as faulty sight or hearing, requiring bend- 
ing of the head and body to see : paraly- 
. ; i~ :f nicies :n cne side :z :le coiy: 
loss of one arm: rapid growth; rickets. 






S vmp 1 ma . — L ateral curvature is 
much more frequent in delicate girls 
Fig. 47 than boys, but may be : ttL 
in robust boys who practice special ex- 
ercises. While the deformity often be- 
gins in young children, it does not com- 
monly become apparent until a later 
period (from eight to fifteen years of 
age), when growth is rapid- The bow- 
ing in the upper part of the spine is 
usually to the right, while the left 
shoulder is lowered and the left hip is 
raised as compared with these points on 
the right side of the body. The condi- 
tion is best observed by marking a line 
along the bony projections of the spine 
down the back (see Fig. -7 . Tiifre 
are frequently no unpleasant symptoms. 

Sometimes, however, there are fatigue from slight causes, general 
irritability and pain in the back or on the left side, if the bowing of 
the spine is toward the right. More often no pain is produced, and 
the mother' s attention is called to a child by the dressmaker, because 
the subject has one breast higher than the other, or because of a 
high or large hip, or high shoulder. Occasionally the disease may 
closely resemble angular curvature, described above, but fever, pain 
on movement, and stiffness of the back are absent. 

Treatment. — In children this deformity of the spine may some- 




7: : 47 — Lateral Ccbvatuke op 

5?z?te 3 : —-z.z - :' r: :_- : : '. -:: 
right shoulder lowered, right 

"Medieal Gynecology.") 



HIP JOINT DISEASE— HIP DISEASE 347 

times be corrected by properly selected exercises or by apparatus. 
Special knowledge and skill are required for this purpose, so that the 
physician should be informed as soon as there is any evidence of 
lateral deformity, and parents should, therefore, be on the lookout 
for the existence of it. 

In order to prevent the condition the general health should be 
improved. Outdoor games are most useful, as swimming (breast 
stroke), riding astride, and games not developing muscles on one side 
of the body — as the side stroke in swimming, playing golf, and the 
use of side saddle. Diseased tonsils and adenoids cause ill health 
and should be removed. Great care should be taken to have shoulder 
straps of clothing hug the neck, as do men's suspenders, and not 
have the weight of the clothing borne by straps over the outer part 
of the shoulders. The eyes and ears should be examined, and if 
errors of vision may be corrected by glasses, or deafness cured by 
removal of adenoids, these matters should be attended to. Faulty 
postures should be remedied. A narrow, straight, high-backed chair 
gives best support to the back. Round shoulders and generally faulty 
position in standing are considered in connection with the conditions 
they produce. 



HIP JOINT DISEASE— HIP DISEASE 

Causes. — The disease of children commonly called hip disease is 
usually an inflammation of the hip caused by the germ of tuberculo- 
isis or consumption. 

Symptoms. — It begins slowly, occurring often, one to four months 
after an injury, as a fall or blow. The first symptom which attracts 
attention to the disease in the child is usually a slight limp and stiff- 
ness of the affected limb in the morning, which may pass off later in 
the day when the child is playing. Sometimes there may be periods 
of weeks when this disappears, only to return in a worse form. More 
often, however, it is constantly present and grows worse. Two to six 
months later pain appears along with the lameness. But the pain at 
first is not as a rule in the diseased hip joint, but in the toe, calf or 



348 DISEASES OF CHILDREN 

leg, or knee. This is apt naturally to mislead parents into think- 
ing the trouble is due to the misnamed ''growing pains/' rheumatism, 
or weakness in the knee, but they must avoid this error. At night 
the child often cries out in pain. 

The position in which the child often holds the affected leg is 
often characteristic. The weight is chiefly borne on the sound limb, 
while the diseased limb is bent slightly at the hip, and the toes and 
the limb are turned outward. At the same time the crease, nat- 
urally present under the buttocks, is less noticeable. At the back of 
the thigh of the affected side the lame leg appears longer than the 
sound one. Later in the disease the lame leg remains bent but is held 
closer to the sound foot, and seems shorter than its fellow, and the 
foot may be turned either outward or inward. 

Treatment. — If the physician's attention is called to it in the 
beginning, almost every case can be cured by rest in bed, splints, and 
apparatus of various kinds. If neglected until a late date abscess 
about the joint, years of suffering, permanent crippling and lame- 
ness, loss of one limb, or even death result. 



BOW-LEG 

Most babies appear to be bow-legged at birth, as they have a ten- 
dency to bring the soles of their feet together, causing the legs to bow 
outward. This condition disappears as the baby grows older, al- 
though occasionally a child is born really bow-legged. Bow-legs more 
often develop, however, between the ages of one and six. and are 
usually due to rickets. The condition may also be seen in robust, 
heavy children, who have been allowed to walk at too early an age. 

Symptoms. — In bow-legs the lower limbs are bent outward in 
most cases, so that the knees are widely separated. The bowing may 
either be of the two bones of the leg, below the knee (most common), 
or of the thigh bone as well, above the knee. 

About one person in five is said to be bow-legged and while the 
condition causes no physical disability or discomfort, it is often a 
repulsive deformity. 



KNOCK-KNEES 



349 



Treatment. — Children having a tendency to bow-legs should not 
be permitted either to walk or stand at an early age. The avoid- 
ance of thick diapers — which prevent the child from holding its 
thighs together — is important. Massage, that is, rubbing the legs 
and kneading the muscles — and making gentle and continued pres- 
sure on the outside of the limbs, so as to bend them inward into a 
straight line, will correct the deformity in in- 
fants, if done persistently several times daily. 

When bow-legs first develop in babies, treat- 
ment directed against rickets is usually desira- 
ble: the child must remain outdoors as much 
as possible; the diet should be improved; one- 
half to one teaspoonful of an emulsion of cod- 
liver oil may be given to the child three times 
daily, and pure cod-liver oil should be rubbed 
all over the body once daily after the bath. If 
the soles of the shoes are made thicker along 
the outer borders it will favor correction of bow- 
legs, when the child begins to walk. In older 

children, when bow-legs are very pronounced and the deformity is of 
long standing, correction can only be secured through the applica- 
tion of apparatus by a surgeon, in patients under three and one- 
half years, or after that age by operation, such as cutting the bent 
part of the bones of the thighs and setting them in proper position. 




Fig. 48. — Bow-legs. 



KNOCK-KNEES 



Causes.' — This is a deformity acquired in infancy, owing to rickets 
— with malformation of the bones of the legs, either above or below 
the knees — but may develop in later life, owing to weakness of the 
ligaments, on the inner side of the knee joint. Prolonged standing, 
carrying heavy loads, and flat feet, favor knock-knees in older patients. 

Symptoms. — It may occur in one or both knees. In knock-knee 
the knees are in close contact, and the feet held apart. A slight degree 
of this condition is seen naturally in women. Knock-knee is not 



350 



DISEASES OF CHILDREN 



recognized by parents so readily as bow-legs. After the child has 
begun to walk, it may show the trouble by an awkward, waddling 
gait, by the knees rubbing together, and by frequently stumbling and 
falling, and the deformity may be seen when the child is standing 
erect or lying with the legs stretched at full length. 

Treatment. — The deformity does not tend to correct itself, as in 
the case of bow-legs. The treatment with 
cod-liver oil and outdoor life, advised for 
bow-legs, is appropriate for knock-knee in 
infancy. Also the legs should be well 
rubbed, kneaded, and straightened by 
pressing upon the inside of the knee joints 
with the palm of the one hand, while the 
ankle is grasped with the other. Such 
treatment should be employed for ten min- 
utes at a time twice each day. 

Children with a separation of two 
inches or less between the ankles, should 
wear shoes with soles made one-quarter of 
an inch thicker on the inner border, and 
should be encouraged to toe in. They 
should be kept off their feet as much as possible, but may ride 
a bicycle or pony. If such measures do not correct the deformity, 
it will be necessary for a physician to apply braces, which will usu- 
ally cure the condition in children under four. After this age an 
operation to break or cut the bones above the knee may be required 
to secure a good result. 




Fig. 49. — Knock-knees. 



WEAK FOOT AND FLAT FOOT 



The patient with weak feet stands and walks with the feet well 
apart and the toes turned out, as in Fig. 50. The foot is rolled in- 
ward so that the inner border of the heels and soles of the shoes are 
worn down. The bony protuberances on the inside of the ankles 
are more prominent, and the part of the shoes covering them may 



WEAK FOOT AND FLAT FOOT 



351 




Fig. 50. — Weak Feet Seen in Front. 



show wear from rubbing together, and many wrinkles may be seen 
running the length of the shoe from heel to toe in persons with weak 
feet. 

On looking at the bared feet in standing, the bulging of the bony 
prominences on the inside of 
the ankles will be present, 
and the inner border of the 
whole foot may be seen to 
be pressed close to the floor 
(flat foot). On viewing 
weak feet in standing, from 
behind, it will be observed 
that the strong cords at the 
back of the ankles are not 
directed directly downward, 
as they should be, but some- 
what outward (Fig. 51). If a person stands and walks with feet 
held apart and toeing out widely, he has weak feet; if in addition 
the soles are dropped, he has flat feet. 

Weak feet are common in children and in adults who are com- 
pelled to stand constantly. The wearing of improper shoes is largely 

the cause of weak feet. Aborigines who 
go bootless are not troubled with weak 
feet. 

The great toe is the great support of 
the foot and prevents it from rolling in- 
ward, as seen in weak feet. In wear- 
ing shoes with narrowed toes the great 
toe is forced in toward the middle line 
of the foot and its support is greatly les- 
sened, while bunion is apt to result. 
When children go barefoot the feet will probably be strong in 
after years unless they are abused by wearing bad shoes. The custom 
of allowing young girls to go about constantly in low shoes is provoc- 
ative of weak feet and ungainly big ankles and, for the latter reason, 
ought to be more readily prevented by parents. 





Fig. 51. — Weak Feet Seen Be- 
hind. 




352 DISEASES OF CHILDREN 

The proper kind of shoes to wear are described on page 272, but 
it might be added that the sole of the shoe under the instep should not 
be too high, so as to fit too snugly under the arch of the foot, as this 
prevents freedom of movement and weakens the arch, as do metal 
plates. 

Flat feet are an aggravated form of weak feet, although they may 
arise from other causes, as from infantile paralysis, fracture of the 
ankle, and from prolonged standing, especially in 
heavy persons. Flat foot depends usually upon 
the weakness of the ligaments or muscles of the 
feet and leg, and as in lateral curvature of the 
spine, there may be structural changes in the bones 
of the feet, in severe cases of long duration. Then 
we have a rigid flat foot, and its position must be 
altered by great force under ether before it can be 

Fig. 52.— A. Print . J b 

of Normal Foot, otherwise properly treated. 

F 0OT . In flat foot the arch under the instep gives way 

so that the bottom of the whole foot becomes flat 
and, in the worst cases, the whole sole of the foot rests on the ground 
in standing. In marked cases, patients stand and walk with the 
toes turned out. This is always a sign of foot weakness; toeing in 
is much to be preferred and this habit should not be interfered with 
by parents. The correct position for the feet in walking and standing 
is the straight one — not toeing in or out. 

To test for flat feet the subject may stand on smoked paper, or 
cover the bottom of the feet with bluing and make a print of the 
soles by standing on wrapping paper. 

The prints of the normal and flat foot may be seen in Figure 52, 
although in moderate flat foot the inner border of the foot may show 
a lighter pressure on the paper, instead of touching it on the whole 
under surface as in Figure 52. 

Symptoms. — Pain and tenderness in the soles of the feet, ankles, 
under the heel, and in the legs, calves, thighs, and back, in standing 
or walking, are the chief symptoms in weak or flat feet of adults. In 
children with weak feet pain is, however, commonly absent. The 
pain may be so great as to cripple the subject, but as soon as he is off 




WEAK FOOT AND FLAT FOOT 353 

his feet it quickly abates. Symptoms come on slowly or rapidly 
in adult life, as in nurses, policemen, stationary engineers and others 
standing on hard, uncarpeted, or cement floors. After a month 
or two of such work the symptoms appear. 

It is not the most marked degree of flat foot that always gives 
the most trouble, but often the slighter forms. The pain of flat 
feet is usually attributed to rheumatism by the pa- 
tient, and backache due to this cause in women is 
often referred to "womb trouble." 

Treatment. —The treatment of weak foot and 
the milder forms of flat foot is much the same. 
The patient should learn to stand and walk with 
feet held straight, not toeing out at all. The old 
idea that it is proper to toe out in standing or 
walking is absolutely wrong. 

In weak feet certain exercises are of great FlG - 53.— Modified 

Thomas Heel. 

value although, in the case of children, games in 
which the child stands on its toes are more practical. Tennis, run- 
ning, jumping, cycling, and ball are therefore useful. Holier skating 
is harmful, but dancing is beneficial. The heels and soles of the 
shoes should be made thicker to the extent of from one-eighth to one- 
half an inch along the inner borders, and it is a good plan to have the 
heel lengthened and widened on the inner border (see Fig. 53) so 
as to give more support to the foot. 

For adults or older children the following special exercises are 
advised : 

1. Walk on the toes, pointing them inward. 

2. Walk on the outer borders of the feet with the toes turned in. 

3. Sit with the soles of the feet together resting on the outer borders. 

4. Stand with the toes turned in and raise one foot quickly, and come 
down slowly on the outer border of the foot. 

Do this twenty times night and morning with each foot (Taylor). 
The use of metal plates for weak foot and flat foot is questionable. 
In some cases of weak feet in adults, plates may be used. In severe 
flat feet in adults it has been the custom to keep the patient off his 
feet for two weeks, to hold the foot in proper position by strapping 



354 DISEASES OF CHILDREN 

with, adhesive plaster, and then to apply proper plates under the 
arch of the feet, made by securing an impression of the feet in plaster 
of Paris. Plates do not correct the deformity, but rather increase 
it by doing away with the normal action of the foot. Sometimes 
they produce abscess by pressure. 

Gradual correction of the feet by strapping with surgeon's plaster 
and the use of felt pads is best when many months can be given to 
the treatment. Teaching the patient to stand and walk properly is 
the final step. The fitting of fiat foot plates by the shoe clerk is as 
much to be deplored, as the fitting of glasses by an optician. The 
cases of rigid flat foot must submit to forcible correction, as noted 
above. 

But in this place the matter of prevention of weak and flat feet 
by correct walking, standing, exercises and shoes, is of much greater 
importance than the details of treatment which properly belong to 
the orthopedic surgeon. 



CHAPTEE VII 

INFECTIOUS DISEASES 

Scarlet fever. Measles. German measles. Smallpox. Chicken pox. 

An infectious disease is a germ disease — that is a disease due to 
a germ or living organism. It is a broad term and includes con- 
tagious diseases, or those acquired by contact of well persons with 
the sick. 

Among the more common of the strictly speaking contagious dis- 
eases, or those we acquire by actual contact with patients suffering 
from the same, are: measles, scarlet fever, German measles, small- 
pox, chicken pox, mumps, infantile paralysis and whooping-cough. 
While some of these may be acquired from the secretions, excre- 
tions, clothing, and premises of the sick, yet recent knowledge shows 
that most people take such diseases from actual contact with indi- 
viduals harboring the special germs on their persons. Such per- 
sons may have recovered and yet carry the germ for months or 
years, or they may have so mild a form of disease that they do 
not stay indoors, or they may be those who are still in the convales- 
cent stage. 

It is safer to use the term infectious or communicable as applied 
to a disease which may be communicated from one person to another, 
since infectious does not imply the means of communication. Thus 
typhoid fever may be contagious and be acquired by direct contact 
with the sick, but it is more often acquired by swallowing milk, water, 
or other food containing typhoid germs. Again, both malaria and 
yellow fever are infectious diseases but are not communicated by con- 
tact with the sick at all, but only through the medium of mosquitoes, 
and are therefore not contagious. 

355 



356 INFECTIOUS DISEASES 

THE INFECTIOUS ERUPTIVE FEVERS 

These, with the exception of smallpox, attack children more 
commonly than adults. As they all begin with fever, and the charac- 
teristic rash does not appear until one to four days after the begin- 
ning of the sickness, the diagnosis of these diseases must always be a 
matter of doubt at the outset. For this reason it should be the 
invariable rule to isolate any child with fever, even if the trouble 
seems to be due to a "cold" or digestive disturbance, in order to 
avoid possible communication of the disease to other children. 

By isolation is meant that a child should stay in a room by him- 
self and the doors should be kept closed, and no children should 
enter, nor should any object in the room be removed to other parts 
of the house after its occupation by the patient. 

While "cold" and indigestion are among the most frequent 
ailments of children, they must not be neglected, because measles 
begins as a bad cold, smallpox like the grippe, and scarlet fever with 
sore throat, or tonsillitis, and vomiting. 

Kindergartens are hotbeds of infection, and it is inadvisable to 
herd any large number of small children at the age when they are 
most susceptible to the common contagious diseases and at which 
the danger is greatest. 

The services of a physician are peculiarly demanded in all cases 
of eruptive diseases in-order that an early diagnosis be made and 
measures be taken to protect the family, neighbors, and community 
from the disease. The failure of parents or guardians to secure 
medical aid for children is regarded by the law as criminal neglect, 
and those responsible are liable to punishment. Health authorities 
require the reporting of all contagious diseases as soon as their 
presence is known, and failure to comply with the law renders the 
offender liable to fine or imprisonment in most places. 

SCARLET FEVER 

There is no difference between scarlet fever and scarlatina. It is 
a popular mistake to suppose that scarlatina is a mild form of scarlet 
fever. 



THE INFECTIOUS ERUPTIVE FEVERS 357 

Scarlet fever occurs most frequently in children between the 
ages of two and six years. Ninety per cent, of cases occur in children 
under ten years of age. Fifty per cent, of children exposed to 
scarlet fever take the disease, while practically all children exposed 
to measles acquire it. This remark applies only to those who have 
not previously had either disease. 

A healthy person who has been exposed, as a nurse, can carry 
the infection to the well by coming directly from the sick. This is 
not the case in measles. However, this method of conveying the 
disease is rare, as students have been in the habit of going from 
scarlet fever wards directly into the general wards for years in a 
large city hospital without giving the disease to the other patients. 

Scarlet fever is almost unknown in infants under one year. It 
is rare in adults, and one attack usually protects the patient from 
another. Second attacks have occurred, but many such are more 
apparent than real, since an error in the diagnosis is not uncommon. 

The disease is communicated from the p'atient at any time after 
the onset until toward the latter end of the peeling period and 
even later, if there, is any discharge from the nose, throat, or ears. 
The disease is communicated then by the scales of skin, breath, urine, 
and discharge from the body. Sores occurring after the disease 
convey the infection. An epidemic has been recorded which origi- 
nated from milk contaminated from a sore on the finger of a milkman 
who had recently recovered from scarlet fever. 

While scarlet fever is a germ disease, the special germ causing 
it has not been discovered. The germs will live in toys, books, 
letters, clothing, wall paper, etc., for weeks. Close contact with the 
patient or exposed persons or objects is apparently necessary to 
acquire the disease. 

Period of Development. — After exposure to the germs of scarlet 
fever usually two to five days elapse before the disease becomes 
manifest. Occasionally the symptoms of the disease occur within 
twenty-four hours of exposure, and rarely they are delayed a week 
or ten days. If a person remains well ten days after exposure, he 
has not been infected. If symptoms occur within two days after 
exposure, the attack is apt to be very severe. 



358 INFECTIOUS DISEASES 

Symptoms. — The onset is usually sudden. It begins with vom- 
iting (in very young children, sometimes with convulsions), sore 
throat, fever, chilliness, headache. The tongue becomes furred. 
The patient often becomes stupid or may be restless and delirious. 
Within twelve to thirty hours or so, the rash appears, first on the 
lower part of the neck and upper part of the chest, and rapidly 
spreads over the trunk, and within forty-eight hours covers legs and 
entire body except the face, which may be only flushed. The rash 
appears as fine, scarlet pin points scattered over a background of 
flushed skin and gives to the patient the general appearance of a 
"boiled lobster," when at its fullest development at the end of the 
second or third day. After this time the rash generally fades away 
and disappears within five to seven days. It is apt to vary greatly 
in intensity from time to time while it lasts. 

As the rash fades, scaling of the skin begins in large flakes and 
continues from ten days to as many weeks, usually terminating by 
the end of the sixth to eighth week. One of the notable features is 
the appearance of the tongue, at first showing red points through 
a white coat and, after this clears away, in presenting a raspberry- 
like aspect. 

The throat is deep red, and the tonsils may be dotted over with 
white spots (see Tonsillitis), or covered with a whitish or gray 
membrane suggesting diphtheria, which occasionally complicates 
scarlet fever. 

The fever is usually high (103° to 107° F.), and the pulse 
ranges from 120 to 150 — both declining after the rash is fully 
developed, generally by the fourth day. The urine is dark and 
scanty. There is, however, great variation in the symptoms both 
as to their presence or absence, intensitv, and time of occurrence and 
disappearance. The seventh to fourteenth day is apt to be the most 
critical period, on account of complications. 

Complications and Sequelae. — These are frequent, and make 
scarlet fever the most dreaded of the eruptive diseases, except 
smallpox. 

Enlarged glands under the jaw, and at the sides of the neck. 
are common, and appear as lumps at these sites; although usually 



THE INFECTIOUS ERUPTIVE FEVERS 359 

not serious, they may enlarge in severe cases and threaten life 
through gangrene, bleeding, and abscess with blood poisoning. Pain 
and swelling in the joints, especially of the knees and elbows, are 
not rare and may be the forerunners of serious inflammation of 
these parts. Pneumonia and pleurisy sometimes occur, and pus 
may form in the chest. One of the most frequent and serious ccm- 
plications of scarlet fever is inflammation of the kidney, occurring 
more often toward the end of the second week of the disease. 

Examination of the urine by the attending physician at frequent 
intervals throughout the course of the disorder is essential, although 
puffiness of the eyelids and face, and of the feet, ankles and hands, 
together with lessened secretion of urine — which often becomes of a 
dark and smoky hue — may denote the onset of this complication. 
The disease of the kidneys usually results in recovery but occasionally 
in death or in chronic Bright's disease. 

Inflammation of the ears with the formation of abscess of the 
middle ear, discharge of matter from the ears externally, and — as 
the final outcome — deafness, are with inflammation of the kidney 
some of the common complications. 

The kidney complication may to a considerable degree be pre- 
vented by the use of a liquid diet. Also spraying the nose and throat 
frequently, and wearing a night cap with ear laps, if the room is 
not warm at night, will aid in preventing the patient from having 
ear trouble. 

Inflammation of the eyelids is an occasional complication. The 
heart is sometimes attacked by the germs of the disease, and per- 
manent damage to the organ, in the form of valvular trouble, may 
result. Blindness and nervous disorders are among the rarer sequels, 
including paralyses and St. Vitus's dance. 

Diagnosis. — When beginning with vomiting, headache, high 
fever, and sore throat, and followed in twenty-four hours by a general 
scarlet rash, the diagnosis is not difficult, but occasionally other 
diseases, such as indigestion, grippe, and German measles, present 
rashes. 

Measles may be distinguished from scarlet fever in that measles 
appears first on the face; the rash is patchy or blotchy, and does 



360 INFECTIOUS DISEASES 

not show for three or four days after the beginning of the sickness. 
The measles patient seems to have a bad cold with fever, cough, 
running at the nose, and sore eyes. German measles is mild, and, 
while the rash may resemble that of scarlet fever, the patient does 
not feel sick and there is rarely catarrh of the nose or eyes. 

In no sickness is the skill of a physician more needed than in 
scarlet fever; first to make the diagnosis, and then to prevent or 
combat the complications which often approach insidiously. 

Outlook. — The average death rate of scarlet fever varies between 
twelve and fifteen per cent. It is very fatal in children about one 
year old, and most of the deaths occur in those under six. The 
mortality varies greatly at different times and in different epidemics 
— as from three to fifty per cent. 

Duration of Contagion. — The disease is commonly considered 
contagious as long as peeling lasts, but, as we have seen, any dis- 
charge from the nose, throat, or ear is capable also of communicating 
scarlet fever after other evidences of the disease are past. Scarlet 
fever patients should always remain in bed three to four weeks, and 
be isolated from eight to ten weeks, without regard to any shorter 
duration of peeling. 

At the close, the patient should be given a bath in a solution of 
corrosive sublimate (1 to 2,000) and the hair should be thoroughly 
washed with soap and water, and then in seventy per cent, alcohol. 
After this is done the patient may be set free from quarantine. 

Treatment. — In case a physician is not obtainable the patient 
must be put to bed in the most airy and sunshiny room, which should 
be heated to 70° F., and from which all unnecessary movables should 
be taken before the entrance of the patient. A flannel nightgown 
and light bed clothing are desirable. 

The fever is best combated by cold sponging, which at the same 
time diminishes the nervous symptoms, such as restlessness and 
delirium. The body should be sponged, part at a time, with water 
at a temperature of about 70° F., after placing a compress of a few 
thicknesses of old cotton or linen, wet with ice or cold water (better 
an icecap) on the forehead. The part should be thoroughly dried 
as soon as sponged, and the process repeated whenever the tempera- 



THE INFECTIOUS ERUPTIVE FEVERS 361 

ture is over 103° F. There is no need to fear that the patient may 
catch cold if care is taken to expose only a portion of the body at a 
time. 

It is well that a rubber bag containing ice, or, failing this, a 
cold cloth, be kept continually on the head while the fever lasts. 
The throat should be sprayed hourly with DobelPs solution and the 
nose also three times daily. In young children a one per cent, 
solution of camphor and menthol in albolene may be dropped in the 
nostrils, with the head thrown back. A half medicine dropperful 
should be used in each nostril three times daily in place of the spray 
just advised. An icebag, or cold cloth frequently wet and covered 
with oil silk or rubber and flannel, should also be applied to the 
outside of the throat. 

The diet should consist of milk, broths, and thin gruels, and 
plenty of water should be given to prevent irritation of the kidneys. 
Cocoa, rice, farina, and milk toast, buttermilk, orangeade and 
lemonade are also desirable. 

A one-half to one per cent, solution of lysol is useful for bathing 
the skin to relieve irritation. During the peeling the whole body 
should be bathed daily with Castile soap and warm water and then 
anointed with carbolized vaselin. The bowels must be kept regular 
with injections, or by the use of mild cathartics, as aromatic fluid- 
extract of cascara or syrup of rhubarb — one-half to one teaspoonful 
or more. 

It is imperative for the nurse or mother to wear a cap and gown 
over the outside clothes, and these should be slipped off at the 
door of the sickroom, and kept there in a box or bag inside the room 
to don before entering again. All others except the doctor must be 
kept out of the sickroom. N~o outsiders should enter the house and 
those who have been exposed should keep away from school and 
other persons until ten days have elapsed. Then those exposed are 
safe, if not already attacked, and may go to school or elsewhere pro- 
viding they stay away from the house until it has been fumigated. Of 
course no pretense has been made to describe the treatment of the 
various complications as a doctor should always care for the case 
when one can be secured. 



362 INFECTIOUS DISEASES 

MEASLES 

Measles is a contagious disease characterized by a preliminary 
stage of fever, and catarrh of the eyes, nose, and throat, followed 
by a general eruption on the skin. One attack usually protects a 
person from another, yet on the other hand second attacks do occur. 
It is more contagious than scarlet fever, and isolation in a room 
in a house is of less value in preventing communication to other 
inmates, whereas in scarlet fever half the number of susceptible 
children in a house may escape the disease by this precaution. 

The germs which cause measles perish very rapidly, and it is 
said that they live but two hours outside of the body ; so that the 
room, and clothing, or other objects exposed to the patient, require 
only a thorough airing for a day to be rendered safe. Whereas, 
in scarlet fever, the danger of the transmission of contagion may 
lurk in infected clothing and other articles for weeks, unless they 
are subject to proper disinfection. 

A patient with measles is capable of communicating the disease 
from the outset, before the appearance of the rash, by means of the- 
breath, discharges from the eyes and nose, tears, saliva, and all 
the secretions. Usually from seven to ten days after the appear- 
ance of the rash the patient is incapable of giving the disease to 
others, but three weeks is none too long to enforce quarantine. 

Close contact with a patient is commonly necessary for one to 
acquire the disease, but apparently it is sometimes carried in the 
clothes by a nurse or third person. It is frequent in infants under 
six months, but most frequent between the second and sixth year. 
Adults are attacked by measles oftener than by scarlet fever. 

Period of Development. — An interval of from seven to sixteen 
days elapses after exposure to measles before the disease becomes 
apparent. 

Symptoms. — The disease begins like a severe cold in the head 
with fever. The eyes are red and watery, the nose runs, and the 
throat is irritable, red, and sore, and there is some cough, chilliness. 
and muscular soreness. The fever, higher at night, varies from 
102° to 104° F., and the pulse ranges from 100 to 120 or more. 



THE INFECTIOUS ERUPTIVE FEVERS 363 

There is often marked drowsiness for a day or two before the rash 
appears. Coated tongue, loss of appetite, occasional vomiting and 
thirst are present during this period. 

The appearance of minute white or bluish-white spots, surrounded 
by a red area, may often be seen in the inside of the mouth, on a 
level with the roots or tops of the back teeth, for some days before 
the skin eruption. This is the measles eruption in the mouth which 
is always looked for by the doctor as the earliest sign of the disease. 

The preliminary period, when the patient appears to be suffering 
from a bad cold, lasts for four days usually, and on the evening 
of the fourth day the rash breaks out. It first appears on the face 
and then spreads to the trunk, chest and limbs. Two days are 
generally required for the complete development of the rash. It 
remains in full bloom for about two days more, and then begins 
to subside, fading completely in another two days — six days in all. 

The rash appears as bright red, slightly raised blotches on the 
face, which is commonly somewhat swollen. The same rash extends 
to the abdomen, back and limbs. At this time the cough may be 
hoarse and incessant, and the eyes extremely sensitive to light. 
The fever and other symptoms abate when the rash subsides and 
well marked scaling of the skin occurs, although it is much finer 
and more branlike than in scarlet fever. 

Complications and Sequelae. — Severe bronchitis, pneumonia, 
croup, laryngitis, sore eyes, ear abscess and deafness, violent diarrhea, 
convulsions, and, as a late result, consumption are sometimes seque- 
lae. (For consideration of these disorders, see special articles in 
other parts of the book.) 

Outlook. — The vast majority of healthy patients over two years 
of age recover from measles completely. In children under two 
years it is a serious disease, and one from which parents should 
by every means protect their infants. Lung complications are par- 
ticularly to be feared in infants and in those suffering from other 
disorders. 

The disease is peculiarly fatal in some epidemics occurring 
among those living in unhealthy surroundings, and in communities 
unaccustomed to the ravages of measles. Thus, in an epidemic 



364 INFECTIOUS DISEASES 

attacking the Fiji Islanders over one-quarter of the whole population 
(150,000) died of measles in 1875. The same applies to the 
Esquimaux and other aboriginal people. Measles is more severe in 
adults than in children. 

Diagnosis. — For one not familiar with the characteristic rash 
a written description of it will not suffice for the certain recognition 
of the disease, but if the long preliminary period of catarrh and 
fever, and the appearance of the eruption on the fourth day, be 
taken into account, together with the existence of inflamed eyes and 
hoarse, hard cough, the determination of the presence of measles 
will not be difficult in most cases. 

Treatment. — The patient should be put to bed in a well venti- 
lated room at a temperature of 68° to 70° F., if possible. If light 
is painful to the eyes, as is usually the case, the room should be 
darkened. 

While by isolation of the patient we may often fail to prevent 
the occurrence of measles in other susceptible persons in the same 
house — because of the very infectious character of the disease and 
because it is probable that they have already been exposed during 
the early stages when measles was not suspected — nevertheless all 
possible precautions should be promptly adopted. For this reason 
other children in the house should be kept from school and away 
from their playfellows. They should, on the other hand, not be sent 
away from home to perhaps spread the disease elsewhere. 

The bowels should be kept open by a daily soapsuds enema, or 
by mild cathartic as a Seidlitz powder. If fever is over 103° F. 
and is accompanied by much distress and restlessness, children may 
be sponged with tepid water, and adults with water at 80° F. every 
two hours, or as directed under Scarlet Fever. 

When cough is incessant, or the rash does not come out well, 
there is nothing better than the hot pack. To give this the patient 
is stripped of all night clothing and wrapped from feet to neck in 
a blanket wrung out of hot water containing two teaspoonfuls of 
mustard to the gallon of water. The wet blanket is then covered 
with two dry blankets and the patient should remain wrapped in 
these three blankets for two or three hours, when the application 



THE INFECTIOUS ERUPTIVE FEVERS 365 

may be repeated if necessary. It is well to keep a cold cloth on the 
head during the process. 

Cough is also relieved by a mixture containing syrup of ipecac, 
twenty drops; paregoric one teaspoonful, for an adult (or one-third 
the dose for a child of six). This should be given in one-quarter 
glass of water and may be repeated every two hours if necessary. 

If there is hoarseness, the neck should be rubbed with a mixture 
of sweet oil, two parts; oil of turpentine, one part; and covered 
with a flannel bandage. 

A solution of boric acid (ten grains of boric acid in one ounce 
of water) is to be dropped in each eye every two hours. Although 
usually mild, the eye symptoms may be very severe and require 
special treatment by an oculist, and considerably impaired vision 
may even result. 

It is well also to drop a solution of menthol and camphor, each 
thirty grains, in one ounce of albolene, in each nostril three times 
daily. A half medicine dropperful should be injected into each 
nostril, with the head held well back. 

Severe diarrhea is combated with bismuth subcarbonate, one- 
quarter teaspoonful, every three hours. For adults the diet consists 
of milk, broths, gruels, eggs — raw, boiled soft or scrambled— and 
toast. Infants on a milk diet should receive the mixture to which 
they are accustomed, diluted with an equal part of barley water. 
Nourishment may be given every two hours, except during sleep. 

The patient should remain in bed ten days, and should stay in 
his room three days after getting up, and after leaving his room 
should stay in the house a week later. This allows a period of 
three weeks "laying up" for an attack of measles. If there are 
other susceptible persons in the house it is wiser for the patient 
to stay in his room the whole of this time. 

The principal danger following an attack of measles is of pneu- 
monia or tuberculosis (consumption), if there is exposure to wet, or 
cold draughts. 



366 INFECTIOUS DISEASES 

GERMAN MEASLES 

(Rubella) 

German measles is related neither to measles nor to scarlet 
fever, although it has received its name because it was thought 
to combine the sore throat of scarlet fever with the rash of measles. 
It is a distinct disease, and persons who have had both measles and 
scarlet fever are still susceptible to rubella. 

One attack of the disease usually protects the patient from 
another. Adults are almost as liable to German measles as children, 
but it is rare in infants. It is very contagious and often occurs 
in widespread epidemics. The breath and emanations from the 
skin apparently transmit the disease — from the appearance of the 
first symptom to the disappearance of the eruption. 

Period of Development. — The period after exposure to German 
measles until the beginning of the disease varies greatly — usually 
about two weeks, but possibly from five to twenty-one days. 

Symptoms. — The rash may be the first sign of the disease and 
frequently is, in children. In others, for a day or two preceding 
the eruption, there may be headache, soreness and redness of the 
throat, the occurrence of red spots on the roof of the back of the 
mouth, chilliness, soreness of the muscles, loss of appetite, and 
watering of the eyes. The marked inflammation of the eyes and 
running from the nose seen in true measles are absent. 

The preliminary symptoms are much milder and shorter in 
duration than in measles, where they last for four days before the 
rash appears; the hard persistent cough of measles is absent in 
German measles. Also, while there is sore throat in German measles, 
there is not the severe form with swollen tonsils covered with white 
spots, so often seen in scarlet fever. Fever is sometimes wholly 
absent in German measles; usually it ranges about 100° F., rarely 
is it over 102° F. 

Thus German measles differs markedly from both scarlet fever 
and true measles. The rash usually appears first on the face, then 
on the chest, and finally covers the whole body, in the space of 
a few hours — twenty-four hours at most. (Before the eruption is 



THE INFECTIOUS ERUPTIVE FEVERS 367 

seen on the skin it may be fonnd on the back of the roof of the 
mouth and throat.) The rash is greatest on the upper part of the 
body. The eruption takes the form of rose-red, round or oval, 
slightly raised spots, from the size of a pinhead to that of a pea, 
and sometimes running together into uniform redness — as in scarlet 
fever. 

The rash remains fully developed for about two days, and often 
changes into a coppery hue as it gradually fades away. There are 
often lumps — enlarged glands — to be felt under the jaw, and on the 
sides and back of the neck which occur more often than in true 
measles. The lumps in the back of the neck just at the lower 
margin of the hair, are the most characteristic. They are found in 
two-thirds of the cases. 

Diagnosis. — The diagnosis, in the absence of a physician, must 
be made on general symptoms, rather than on the rash which re- 
quires great experience for its recognition, as it is subject to wide 
variation in appearance, now simulating measles and again scarlet 
fever. 

German measles differs from true measles in the following 
points : the first symptoms before the rash are mild, short, or absent, 
and the cold in the nose and eyes as well as the cough are absent, 
or slight, as compared with these symptoms in true measles. The 
rumps in the neck in German measles are more pronounced than they 
are in true measles. 

The onset in German measles is not sudden, as in scarlet fever, 
where it is accompanied with vomiting; while the sore throat and 
fever are much milder in German measles. The peeling, so promi- 
nent in scarlet fever with the subsidence of the rash, may be present 
or absent in German measles. If present, the peeling is much finer 
than in scarlet fever or true measles. 

Outlook. — Recovery from German measles is the rule and usually 
without complication or delay. Very rarely have Bright's disease, 
joint inflammation, pneumonia, jaundice and diarrhea been com- 
plications. 

Treatment. — Little or no treatment is required. The patient 
should remain in bed in a darkened room, on a light diet, while 



368 INFECTIOUS DISEASES 

the fever lasts, and be isolated indoors from others until all signs 
of the eruption have passed. 

The eyes should be treated with boric acid as in measles; the 
diet during the fever may consist of milk, eggs — soft boiled, and 
dropped — and eggnog; broths, thin cereals, and beef juice, for 
adults or children, while bottle-fed infants should have their milk 
diluted one-half with barley water. 

A bath and fresh clothing for the patient, and thorough cleaning 
and airing of the sickroom and clothing, are usually sufficient without 
chemical disinfection, after the passing of the disease. 

SMALLPOX 

Smallpox is one of the most contagious diseases known. Only 
one person in a hundred is immune unless protected by a previous 
attack of the disease or by vaccination. One is absolutely safe from 
smallpox if recently and successfully vaccinated, and thus has one 
of the oldest and most frightful and fatal scourges (one-half million 
deaths a year in Europe before vaccination) of mankind been robbed 
of its dangers. 

The contagium is probably chiefly derived from the scales and 
particles of skin of the patient after eruption, but the disease has 
been conveyed by grafting the skin of a patient on a normal person 
before the eruption appeared, so that smallpox may be contagious 
after the symptoms have begun but before the eruption appears. 
The special germ causing smallpox has not been isolated. It is riot 
necessary to come into direct contact with a patient to contract the 
disease; it may be transmitted some little distance in the air and 
possibly outside of the sickroom. Careful study appears to show 
that smallpox hospitals do not threaten the public through the air, 
but only through persons entering and leaving them. Smallpox 
may be conveyed by a healthy third person, who has come in 
contact with the sick, or by the excretions, clothing, and surroundings 
of patients. The contagium lingers long in the sickroom. 

One attack almost invariably protects against another. All ages 
are liable to smallpox, and it is particularly fatal in children under 
ten, so that vaccination in infancy is of vital importance. 



THE INFECTIOUS EEUPTIVE FEVERS 369 

Development. — An interval of ten or twelve days usually elapses 
after exposure to smallpox before the appearance of the first symp- 
toms. This period may vary from five to twenty days. 

Symptoms. — There is a preliminary period of three days after 
the beginning of the disease before the eruption appears. If the 
onset is mild, then the severer forms are not probable. Smallpox 
begins suddenly with symptoms which simulate severe grippe — for 
which the disease is often taken at this time. The patient is seized 
with a chill, severe pains in the head, back and limbs, loss of appetite 
and dizziness on sitting up and high fever — 103° to 105° F. The 
chills may be often repeated and in young children convulsions 
may take their place. 

A fleeting rash on the lower part of the belly, sides of the chest, 
thighs, and armpits may appear on the first or second day. It may 
resemble scarlet fever or measles, or take various forms, and is seen 
only in ten to sixteen per cent, of cases, and rapidly disappears. 
Delirium may be present when the fever is high and the face is 
flushed. The symptoms in mild cases may disappear after two or 
three days and the patient may even go out before, or as the eruption 
appears. 

The true eruption usually occurs on the fourth day and is 
descending, i.e., beginning on the first day on the forehead and 
face and on the front of the forearms ; it is seen the next day on the 
body, and then on the front of the legs. Of course this progress is 
not followed uniformly, but this is the tendency. 

The eruption takes four forms successively: first as red spots, 
like flea bites, near the hair on the forehead and face, soon becoming 
red, hard, shotlike pimples. Then on the second or third day of 
the eruption these pimples become tipped with little blisters with 
depressed centers. Three days later the blisters become filled with 
matter or pus and are surrounded by a red area, and the skin is 
drawn tight and swollen. 

The eruption is now at its height. The red areas run together, 
the swelling of the face gives rise to pain and distortion of the 
features so that the eyelids are swollen and closed, and the patient 
becomes frightfully disfigured and well-nigh unrecognizable in 



370 INFECTIOUS DISEASES 

severe cases. Fever, which was absent or slight at the beginning of 
the eruption, now reappears and may mount again to 103° to 105° 
F. and then it gradually falls in convalescence. Delirium is common 
at this time, and patients need constant watching to prevent their 
escape from bed. A peculiar disagreeable odor is exhaled from 
the skin. 

The eruption now takes the appearance of roundish, yellow- 
gray pustules, the change beginning on the face, and following the 
same order as the breaking out of the eruption. These pustules 
begin to dry after a few days and matter exudes and forms large, 
yellowish or brownish crusts, about the tenth or eleventh day of 
the disease, which after a week or so leave red marks, and in severe 
cases there is pitting. The eruption is usually most marked on the 
face, hands, and forearms, and least on the belly, and groin and 
legs, but may be plentiful on the upper part of the back and neck. 

In the severe or confluent form the separate eruptive points run 
together so that face and hands present one distorted mass of abscess 
formation, swelling and crusting. In these pitting invariably follows, 
while in those in which the eruption remains distinct, pitting is not 
certain to ensue. The danger depends upon the number of pustules 
on the face. 

A more serious form is that styled "black smallpox," in which 
the skin becomes of a dark purplish hue, from the fact that each 
pustule is a small blood blister, and bleeding occurs, from the nose, 
mouth, bowels, kidneys, womb, etc. These cases are, almost without 
exception, fatal in five or six days. The following is a summary 
of the order of progress in the ordinary form of smallpox. 

Period of development: — 10 to 12 days from time of exposure. 

Period of invasion with high fever, subsiding at the beginning of 
rash: — 3 days' duration. 

Eruption of red spots and pimples: — 3 days' duration! .. , , 

Eruption of blisters : — 2 days' duration J q1 

Matter forming in eruption with high fever: — 3 days' duration. 

Drying and crusting to time of falling of same with disappearance 
of fever: — 7 days' duration. 

This makes 19 days in all. 



THE INFECTIOUS ERUPTIVE FEVERS 371 

During the last decade the outbreaks of smallpox have commonly 
been very mild and have not followed the course just noted. There 
may be severe headache, backache, fever (103° F.) and vomiting at 
the beginning, with an eruption of perhaps only a dozen or so of 
pimples on the face and hands on the third or fourth day. After 
the first few days the fever and all the disagreeable symptoms may 
subside and the patient feel perfectly well. Even when the eruption 
is plentiful it may not go on to formation of matter, but after five 
or six days the blisters may become dry and hard or wartlike, and 
disappear. 

Although the death rate has been exceedingly low of late it is 
perfectly possible for a person to contract the most severe form of 
smallpox from one of these mild and often unrecognized cases — this 
unfortunately has happened. 

Varioloid is a milder form of smallpox which occurs in persons 
who have been vaccinated. It is similar to the cases just described, 
and although the headache, backache, fever, and vomiting may be 
sudden and severe, the fever and other symptoms abate on the 
appearance of the eruption, chiefly on the face and hands. The 
rash goes through its phases in about half the usual time without 
any secondary fever (with the formation of pustules), and without 
scarring. Occasionally cases of mild smallpox have occurred with 
the appearance of eruption without any preliminary fever, head- 
ache, backache, or vomiting. 

Diagnosis. — The milder forms of smallpox are most often mis- 
taken for chickenpox, but the preliminary three days of fever, 
headache, backache, and vomiting do not occur in chickenpox. In 
the latter there may, however, be a period of twenty-four hours in 
which such symptoms occur, but milder. In chickenpox the eruption 
is particularly seen on the back and chest. An outbreak of a con- 
tagious pustular eruption in adults would suggest smallpox since 
chickenpox is a disease of children. If a patient with suspected 
smallpox had been recently and successfully vaccinated the diagnosis 
would be certainly doubtful. 

Smallpox is very rare in those who have already had the disease 
or have been successfully vaccinated within a few years. The pre- 



372 INFECTIOUS DISEASES 

liminary three-day period of fever, headache, backache, and vomiting 
must guide the layman rather than the peculiar appearances of the 
eruption which requires educated skill and experience to recognize. 

This long period of sickness before the appearance of the rash 
is seen in only one other contagious, eruptive disease — measles. 
But in measles the marked catarrh of the eyes and nose and the 
rising fever with the coming out of the rash are characteristic. In 
smallpox the fever falls as the rash appears and the sore eyes and 
running nose are not pronounced. 

The mild type of smallpox should be treated just as rigidly as 
severe cases with regard to isolation and quarantine, being more 
dangerous to the community because lightly judged. 

Outlook. — During the last decade smallpox has been very mild 
in the United States. In some 54,000 cases in 1909 to 1910, the 
death rate was about one per cent. The United States Public Health 
sendee stated in their report (Jan., 1915) that the death rate was 
only about one in 500 cases of smallpox in this country. Some au- 
thorities believe that vaccination for generations has established a 
partial immunity in the race, but this is mere hypothesis. 

It has been said that we have a new disease; but such a state- 
ment is neither new nor true. In the history of the disease great 
variability in the virulence of smallpox has been often noted. There 
have been virulent outbreaks in places only recently. 

The death rate in varioloid is about the same as in recent mild 
smallpox (1.3 per cent.). 

Smallpox occurring within five years of a successful vaccination 
is rarely fatal. The disease has been fatal in eight per cent, of those 
vaccinated once, and in four per cent, of those vaccinated twice. In 
former epidemics of smallpox about one-half the patients unprotected 
by previous vaccinations have died. 

Complications. — Complications are not the rule even in severe 
smallpox. Inflammation of the eyelids is, however, frequent and 
also boils, in the later stages. Delirium, convulsions, and diarrhea 
are common in children but may be regarded as almost natural 
symptoms in them. 

Among the rarer complications are: laryngitis, pneumonia, in- 



THE INFECTIOUS ERUPTIVE FEVERS 373 

sanity, disease of the heart, paralysis, various skin eruptions, inflam- 
mation of the joints, eyes and ears, and baldness. 

Prevention. — This is of chief importance. Vaccination marked 
an era in medicine when Jenner gave his discovery to the world, 
in 1796, and when it was introduced into this country in 1800 
by Prof. Waterhouse of Harvard. It has hitherto stood alone as 
the single example of a means of positive protection in a conta- 
gious disease but it now has a rival in vaccination against typhoid 
fever. 

Vaccination against smallpox consists in the inoculation of a, 
human being with matter taken from one of the eruptive points on 
the body of a calf suffering from cowpox. Whether cowpox is a 
modified form of smallpox or a distinct disease is unknown. 

The period of protection afforded by vaccination is uncertain, 
because it varies with different individuals. In a general way 
immunity for four or five years is thus secured ; ten or twelve years 
after vaccination the protection is certainly lost, and smallpox may 
then be acquired. 

Every person should be vaccinated between the second and third 
month after birth, and again between the ages of ten and twelve, 
and at other times when an epidemic threatens. An unvaccinated 
person should be vaccinated and revaccinated, until the result is 
successful, as immunity to vaccination in an unvaccinated individual 
is one of the rarities in medicine. When unsuccessful, the vaccine 
matter or technic is faulty. 

A person constantly exposed to smallpox should be vaccinated 
every few weeks — if unsuccessful no harm or discomfort follow; if 
successful it proves liability to smallpox. In a person previously 
successfully vaccinated, the vaccination may "take" again any time 
after four or five years, and, in event of possible exposure to small- 
pox, he should be revaccinated several times within a few weeks — 
if the vaccination does not take — before the attempt is given up. 

An unvaccinated person, who has been exposed to smallpox, 
may often escape the disease if successfully vaccinated within three 
days of the date of exposure, but is not sure to do so. 

Diseases are not introduced with vaccine matter, as formerly 



374 INFECTIOUS DISEASES 

occurred when matter was taken from human beings. Most of the 
inflammation of the vaccinated parts may be avoided by cleanliness 
in vaccinating and proper care of the wound afterwards. 

It is an extraordinary fact that many persons of some intelligence 
to-day refuse to acknowledge the wonderful preventive effect of vac- 
•cination and fear its immediate action as likely to lead to some 
mysterious permanent damage. There were only two deaths (from 
erysipelas i in two and one-half million vaccinations in Germany. 
These could probably have been prevented by cleanliness. 

In the absence of a physician vaccination may be properly done 
by an intelligent person when the circumstances demand it. Vac- 
cination is usually performed in the depression on the outside of 
the left arm a few inches below the shoulder. If done on the leg 
the vaccination is apt to be much more troublesome and may confine 
the patient t 

The arm should be thoroughly washed with soap and water, from 
shoulder to elbow, and then with alcohol diluted one-third with 
water. When the alcohol is evaporated, and the arm is wholly dry. 
the ivory t: lint containing the vaccine matter is withdrawn from its 
3ase and the skin is scratched over an area about one-third of an 
inch square. The object is not to draw blood out but to remove the 
outer layer of the -"_::::. so that it appears red and moist but does 
not bleed much. TL:s is accomplished by light scratching in various 
directions. If there is much bleeding the vaccine matter is washed 
away. 

Then the vaccine matter (in glycerin on the end of the ivory 
point) is gently rubbed into the scratches with the flat surface of 
the point. These are the most convenient points. If the vaccine 
matter is contained in small glass tubes, the scratching is done with 
a cold needle which has been previously heated red hot over a name. 
The needle must not touch anything thereafter until the skin is 
scratched with it. The heating is done to sterilize the needle. After 
this both ends are broken from the glass tubes and the vaccine matter 
is squirted on the raw place on the arm (with the rubber bulbs 
for the purpose 1 , and rubbed in gently by means of the side of the 
needle point. Sometimes the vaccine matter is supplied dry on 



THE INFECTIOUS ERUPTIVE FEVERS 375 

ivory points when they are dipped into water which has been boiled 
and cooled, and rnbbed thoroughly over the raw area. 

It is safer to make a second vaccination at the same time, an inch 
or two below the first, to increase the chance of taking. 

The arm must remain bare and the vaccination mark untouched, 
after the vaccine matter has been rubbed in, until the surface of the 
raw spot is perfectly dry; this may take half an hour. Then a 
half dozen layers of sterilized surgical gauze, reaching halfway about 
the arm for an inch or two above and below the vaccination marks, 
should be kept in place by strips of adhesive plaster for at least 
three days, or an absolutely clean handkerchief may be bound about 
the arm, and folded over the vaccination and kept in place by sewing 
or by pinning with safety pins. The protection is intended to keep 
germs from being rubbed into the wound. 

After three days the covering may be removed and soft, clean, 
old cotton or linen should be daily pinned inside the sleeve of the 
undergarment to come in contact with the vaccination. If the scab 
is knocked off and an open sore results, it should be treated like 
any wound by antiseptic powders (as boric acid) and should be 
covered with sterile gauze. 

If the vaccination "takes" it passes through several phases. On 
the third day following the vaccination a red pimple forms at the 
point of introduction of the matter, and this is surrounded by a 
red zone. Some little fever may occur. On the fifth day the pimple 
has become capped with a blister having a depressed center and 
containing a clear fluid, and there is a certain amount of hard 
swelling, itchiness, and pain in the surrounding parts. A sore lump 
(swollen gland) is often felt in the armpit. 

The full development is reached on the eighth day when the 
pimple (or truly a pustule) is full and rounded, contains matter or 
pus, and is surrounded by a large area of redness. From the 
eleventh day the vaccination sore dries, and a brown scab forms 
over it at about the end of the second week, and the redness and 
swelling gradually depart. At the end of the third week the scab 
drops off, leaving a pitted scar or mark. It will be seen that the 
changes are identical with those described in smallpox. 



376 INFECTIOUS DISEASES 

!Not infrequently the vaccination results in a very slight pimple 
and redness in a week or ten days, in which case the vaccination 
should be repeated, as this is a kind of abortive form. 

Unless the course of a vaccination follows very closely that 
described it cannot be regarded as successful, although after the 
first one or two vaccinations the result is often not so severe, and 
the time of completion of the various stages may be somewhat short- 
ened. In rare cases an eruption, resembling that at the site of vac- 
cination, appears on the vaccinated limb or becomes general on the 
body, due to inoculation by scratching, or hives may be present. 

Treatment. — The special treatment of smallpox is largely a mat- 
ter of careful nursing. A physician or nurse can scarcely lay claim 
to any considerable degree of heroism in caring for smallpox patients 
(notwithstanding frequent, foolish newspaper reports) as there is 
not the slightest danger of contracting the disease provided one has 
been recently and successfully vaccinated. 

The patient should be quarantined in an isolated building, and 
all unnecessary articles should first be removed from the sickroom, 
in the way of carpets, curtains, and other such furnishings. It is 
well that the room be darkened to save the eyes. The diet should 
be liquid — of milk, broth, and gruels. 

Sponging throughout the course of the disease is essential; first 
with cool water (as directed for scarlet fever) to relieve the fever 
and itching, while cold should be also applied to the head to prevent 
delirium and headache. The cold pack is still more efficient. To 
apply this, the patient should be wrapped in a sheet wrung out of 
water at a temperature between 6S° and 7o c F. The sheet should 
surround the naked body from neck to feet, and should be tucked 
between the legs and between the arms and body. The whole is then 
covered with a dry blanket, and a cold, wet cloth or icebag is placed 
upon the head. The patient may be permitted to remain in the 
pack for an hour, when it may be renewed if necessary to allay 
fever or restlessness; otherwise it may be discontinued. The cold 
sponging or cold pack is advised when the temperature is over 
102.5° F., and when with fever there is restlessness and delirium. 

Great cleanliness is important throughout the disease: the bed- 



THE INFECTIOUS ERUPTIVE FEVERS 377 

clothes should be changed daily and the patient sponged two or three 
times daily with warm water, when there is no fever. Cloths wet 
with corrosive sublimate solution (1 part in 5,000 of water) should 
be kept continuously on the face and hands. Holes should be cut 
in the face mask for the eyes, nose and mouth, and the whole 
covered with a similar mask of oil silk to keep the moisture in. 
Such applications give much relief, and to some extent prevent pit- 
ting. The hair must be cut short and crusts on the scalp treated 
with frequent sponging and carbolized vaselin to soften them and 
hasten their falling. Boric acid solution should be applied frequently 
to the eyes, as recommended in measles, and the throat sprayed 
every few hours with Dobell's solution. 

Diarrhea in adults may be checked with teaspoonful doses of 
paregoric 1 given in water hourly. Vaselin and cloths used on one 
patient must not be employed upon another, as boils are readily thus 
propagated. Each patient should have a special tube of vaselin. All 
clothing, dishes, glasses, knives, forks and spoons, etc., coming in 
contact with a patient must be either boiled ten minutes, or soaked 
in a three per cent, solution of carbolic acid for twenty-four hours, 
or burned. 

When the patient is wholly free from scabs, after bathing and 
putting on disinfected or new clothes outside the sickroom, he is fit 
to reenter the world. 

CHICKENPOX 

(Varicella) 

Chickenpox is a contagious disease, chiefly attacking children. 
While it resembles smallpox in some respects, at times simulating 
the disease so closely as to puzzle physicians, it is a distinct disease 
and in no way related to smallpox. This is shown by the fact that 
chickenpox sometimes attacks a patient suffering with, or recovering 
from, smallpox. Neither does vaccination or a previous attack of 
smallpox protect an individual from chickenpox. 

Chickenpox is not common in adults, and its apparent presence 

i Paregoric is a preparation of opium, and may only be bought on a doe- 
tor 's prescription. 



378 INFECTIOUS DISEASES 

in a grown person should awaken the liveliest suspicion that the 
case be one of smallpox, since this mistake has been frequently 
made, and with disastrous results, during an epidemic of mild 
smallpox. 

One attack of chickenpox usually protects against another, but 
two or three attacks in the same individual are not unknown. 

The disease is capable of transmission from the patient to another 
person from the time of the first symptom to the disappearance of 
the eruption. The disease ordinarily occurs in epidemics, but 
occasionally in isolated cases. 

Period of Development. — An interval of two weeks commonly 
elapses after exposure to the disease before the occurrence of the 
first symptom of chickenpox ; but this period may vary from thirteen 
to twenty-one days. 

Symptoms. — The characteristic eruption may appear without 
general symptoms. More commonly there is some fever (99° to 
102° F.) and perhaps a slight chill, pains in the back and legs, and 
vomiting, lasting for twenty-four hours before the eruption 
is seen. Earely there may be high fever, convulsions, delirium, sore 
throat, and a general redness of the skin during this twenty-four 
hour period preceding the eruption. 

The eruption is first seen on the back or chest, in most cases, 
but in some it occurs first on the face, temples, and forehead. It 
consists of small red pimples which rapidly develop into pearly 
looking blisters about as large as a small pea, and rarely as large as 
a finger nail, and are sometimes surrounded by a red blush on 
the skin. 

The change from the red pimple into the blister form takes but 
a few hours. These blisters vary in number from a dozen or so 
to several hundred. They do not run together, and in three or 
four days dry up, become shriveled, puckered, covered with a dark 
brown or blackish crust, and drop off, leaving only temporary red 
spots in most cases. If the child scratches much, however, sores 
may form and leave bad scars on the skin. 

Occasionally the eruption comes out in the mouth, on the lips, 
tongue, nose, ear and foreskin in males, and about the sexual organs 



THE INFECTIOUS ERUPTIVE FEVERS 379 

in females. In the mouth the eruption presents the appearance of 
white spots surrounded by a deeper red area. Fever is irregular 
and does not abate with the appearance of the eruption. 

During the first few days successive crops of fresh red spots 
surmounted by blisters are seen, so that while the first crop is drying 
up the second may be in full development. This forms one of the 
distinguishing features of chickenpox as compared with smallpox 
in which the eruption does not appear in successive crops. In 
chickenpox the eruption is more often on the part of the skin which 
is covered, while in smallpox the eruption is more often first seen 
on the face and hands. Still in some cases the eruption in chicken- 
pox is seen on the scalp and forehead, palms, soles and forearms, 
and on the inside of the cheek and roof of the mouth. 

The blisters are rarely filled with matter or pus, as in smallpox, 
unless they are scratched, and this should be guarded against — 
especially on the face, to prevent the formation of scars. 

Diagnosis. — The diagnosis between chickenpox and smallpox is 
sometimes puzzling and demands the skill of an experienced physi- 
cian. When one is unavailable the following points may serve to 
distinguish the two diseases : — 

Smallpox usually begins like a severe attack of grippe with 
pain in the back and head and generally about the body, with nausea, 
vomiting, high fever (103° to 104° F.). These symptoms last two 
or three days and may completely subside before the rash appears. 
In chickenpox this preliminary sickness is absent, or does not begin 
until twenty-four hours before the eruption appears. The eruption 
of smallpox usually occurs first on the forehead, near the hair, or 
on the wrists, palms of the hands or soles of the feet, and on the 
arms and legs, but sparsely on the body. The eruption does not 
appear in successive crops in smallpox. Chickenpox is more often 
a disease of childhood; smallpox attacks persons of all ages. The 
crusts in chickenpox are thin and appear in four or five days, while 
those of smallpox are large and yellow, and occur after eight or 
ten days. It must be kept in mind, however, that chickenpox in 
adults is much more severe than in children and the rash more 
widespread. 



380 INFECTIOUS DISEASES 

Outlook. — Chickenpox almost invariably results in a rapid recov- 
ery without complications or sequels. Young patients often feel 
well throughout the course of the disease, which lasts from eight 
to twelve days. 

Rarely inflammation of the kidneys occurs three to fourteen 
days after the disappearance of the rash, and pneumonia, lumps in 
the back of the neck or swollen glands, and many other complica- 
tions have occasionally been seen. 

Treatment. — Children should be kept in bed until the eruption 
has reached the crust stage. To prevent scratching the skin may be 
bathed with a solution of baking soda and tepid water (one teaspoon- 
ful to the pint) and then covered with carbolized vaselin. The diet 
should consist of milk, broths, thin cereals, soft boiled or dropped 
eggs, and toast. 

Patients should be kept in the house until all signs of the erup- 
tion are passed, and then receive a good bath and fresh clothing 
before mingling with others. The sickroom should be thoroughly 
cleaned and aired, although chemical disinfection is not essential. 
The services of a physician are always desirable in order that it 
may be positively determined that the disease is not a mild form of 
smallpox. 



CHAPTER VIII 
INFECTIOUS DISEASES {Continued) 

Mumps. Whooping-cough. Typhoid fever. Epidemic cerebrospinal menin- 
gitis. 

MUMPS 

Mumps is a contagious disease characterized by inflammation of 
the parotid glands — situated below and in front of the ears — and 
sometimes of the other salivary glands below the jaw, and rarely of 
the testicles in males and the breasts of females. 

Swelling and inflammation of the parotid gland may occur from 
injury; it may also occur as a complication of other diseases, such 
as scarlet fever, typhoid fever, etc. However, such conditions are 
wholly distinct from the disease under discussion. 

Mumps is more or less constantly prevalent in most large cities, 
more often in the spring and fall, and is often epidemic, attacking 
ninety per cent, of young persons who have not previously had the 
disease. It is more common in males, affecting children and youths, 
but rarely infants or those past middle age. One attack usually 
protects against another. 

Development. — A period from two to three weeks elapses, after 
exposure to the disease, before the first signs develop. The germ 
has not yet been discovered, and the means of communication are 
unknown. The breath has been thought to spread the germs of the 
disease, and mumps can be conveyed from the sick to the well, by 
nurses and others who themselves escape. 

Symptoms. — Sometimes there is some preliminary discomfort be- 
fore the apparent onset. Thus, in children restlessness, peevishness, 
languor, nausea, loss of appetite, chilliness, fever, and convulsions 
may usher in an attack. 

381 



382 INFECTIOUS DISEASES 

Mumps begins with pain and swelling below the ear on one side. 
Within forty-eight hours a large, firm, sensitive lump forms under 
the ear, pushing up the lobe, and extending forward on the face, 
and downward and backward in the neck. The swelling is not 
generally very painful but gives a feeling of tightness, and disfigures 
the patient. It makes speaking and swallowing difficult ; the patient 
refuses food, and talks in a husky voice ; chewing causes severe pain. 
After a period of two or four days the other gland usually becomes 
similarly inflamed, but occasionally only one gland is attacked. 

There is always fever from the beginning. At first the tempera- 
ture is about 101° F., rarely much higher than 103° or 104°. The 
fever continues four or five days and then gradually declines. The 
swelling reaches its height in from two to five days, and then after 
forty-eight hours, slowly subsides, and disappears entirely within ten 
to fourteen days. The patient may communicate the disease for ten 
days after the fever is past, and needs to be isolated for that period. 

Earache and noises in the ear frequently accompany mumps, 
and rarely abscess of the ear and deafness result. The most common 
complication occurs in males past puberty, when during recovery 
or a week or ten days later, one or both testicles become painful and 
swollen, and this continues for as long a time as the original mumps. 
Less often the breasts and sexual organs of females are similarly 
affected. 

Complications and Sequelae. — Recovery without mishap is the 
usual result in mumps, with the exception of involvement of the 
testicles. Rarely there are high fever, delirium, and great prostra- 
tion. Sometimes after inflammation of both testicles in the young 
the organs cease to develop, and remain so, but sexual vigor is usually 
retained. Occasionally abscess and gangrene of the inflamed parotid 
gland occur. Recurring swelling and inflammation of the gland 
may take place, and permanent swelling and hardness remain. 
Meningitis, nervous and joint complications are among the rarer 
sequelae. 

Treatment. — The patient should remain in bed while the fever 
lasts. A liquid diet is advisable during this time. Fever may be 
allayed by frequent sponging of the naked body with tepid water. 



WHOOPING-COUGH 383 

High fever and delirium demand the constant use, on the head, of 
the icecap (a rubber bag, made to fit the head, containing ice). 

The relief of pain in the swollen gland is secured by the frequent 
application of a thick layer of sheet cotton, large enough to cover 
the whole side of the neck, wrung out of hot water and covered with 
oil silk or rubber sheeting; this is kept in place by a bandage. 

Paregoric may be given for the same purpose — a tablespoonful 
for adults; a teaspoonful for a child of eight or ten — well diluted 
with water, and not repeated inside of two hours, and not then unless 
the pain continues unabated. 

Inflammation of the testicles demands rest in bed, elevation of 
the testicle on a pillow after wrapping it in a thick layer of absorbent 
cotton, or applying hot compresses, as recommended for the neck. 
After the first few days of this treatment, a suspensory bandage 
should be adjusted, which can be procured at any apothecary shop, 
and the following ointment should be applied daily: guaiacol, sixty 
grains; lard, one-half an ounce on a cotton cloth over the swollen 
testicle. 

The application of a suspensory bandage at the onset of mumps 
may prevent swelling of the testicles. 

WHOOPING-COUGH 

; Whooping-cough is a contagious disease characterized by fits of 
coughing, during which a whooping or crowing sound is made follow- 
ing a long drawn breath. 

Whooping-cough is generally taken through direct contact with 
the sick, rarely through exposure to the sickroom, or to persons or 
clothing used by the sick. The germ which causes the disease exists 
in the mucus of the nose and throat. Whooping-cough is usually 
more or less prevalent in all thickly settled civilized communities, at 
times is epidemic, and often follows epidemics of measles. 

It occurs chiefly in children from six months to six years of 
age. Girls and all weak and delicate subjects are slightly more 
susceptible to the disease. Some children are naturally immune to 
whooping-cough. One attack usually protects against another. 

Development. — A variable period elapses between the time of 



384 INFECTIOUS DISEASES 

exposure to whooping-cough and the appearance of the first symptoms. 
This may be from two days to two weeks, usually seven to ten days. 

Symptoms. — Whooping-cough begins like an ordinary cold in 
the head, with a cough which grows worse at night, and which per- 
sists. The coughing fits increase, and the child gets red in the face, 
has difficulty in getting his breath during these spells and sometimes 
vomits when the attack is over. After a variable period — from a 
few days to two weeks from the beginning of the cough — the peculiar 
feature of the disease appears. The child coughs fifteen or twenty 
times, without drawing breath, the face swells and grows blue, the 
eyeballs protrude, the veins stand out, and the patient appears to 
be suffocating, when at last he draws in a long breath with a crowing 
or whooping sound, which gives rise to the name of the disease. 

Several such fits of coughing may follow one another and are 
often succeeded by vomiting and the expulsion of a large amount 
of phlegm or mucus, which is sometimes streaked with blood. In 
mild cases there may be six to twelve attacks in twenty-four hours; 
in severe cases from forty to eighty. The attacks last from a few 
seconds to one or two minutes. Occasionally the whoop comes before 
the coughing fit, and sometimes there may be no whoop at all, only 
fits of coughing with vomiting. Between the attacks, puffmess of 
the face and eyes and blueness of the tongue persist. 

The coughing fits and whooping usually last from three to six 
weeks, but the duration of the disease is very variable. Occasionally 
it lasts many months, especially when it occurs in winter. The 
contagiousness of whooping-cough continues about two months, or 
ceases before that time with the cessation of the cough. Oftentimes 
there may be occasional whooping for months; or, after ceasing 
altogether for some days, it may begin again. In neither of these 
conditions is the disease considered still contagious after two months 
When an attack of whooping is coming on, the child often seems to 
have some warning, as he appears terrified and suddenly sits up in 
bed, or, if playing, grasps hold of something, or runs to his mother 
or nurse. Coughing fits are favored by emotion or excitement, by 
crying, singing, eating, drinking, sudden change of temperature, and 
bv bad air. 



WHOOPING-COUGH 385 

Complications and Sequelae. — These are many and make whoop- 
ing-cough a critical disease for very young children. Bronchitis and 
pneumonia often complicate whooping-cough in the winter, and diar- 
rhea frequently occurs with it in summer. Convulsions not infre- 
quently follow the coughing fits in infants, and, owing to the amount 
of blood forced to the head during the attacks, nosebleed and dark 
spots on the forehead and surface of the eyes appear from the 
breaking of small blood vessels in these places. Severe vomiting 
and diarrhea occasionally aggravate the case, and pleurisy and 
consumption may occur. 

The violent coughing may permanently damage the heart. Rup- 
ture of the lung tissue happens from the same cause, and paralysis 
sometimes follows the breaking of a blood vessel in the brain. But 
in the vast majority of cases in children over two years old no 
dangerous sequelae need be feared. 

Outlook. — Owing to the numerous complications, whooping-cough 
must be looked upon as a very serious disease, especially in infants 
under two years, and in weak delicate children. It causes more 
deaths than scarlet fever or measles, ranking fourth as a cause of 
death in children (1902 census), the death rate varying from three 
to fifteen per cent. (27 per cent, during the first year) at different 
times and under different circumstances. For this reason it is of 
importance that a physician's services should be secured when pos- 
sible. 

Treatment. — A host of remedies are used for whooping-cough, 
but no single one is at all times the one to be relied upon. It is 
often necessary to try different medicines until the one which excels 
is found. 

Fresh air is of greatest importance. Patients should be strictly 
isolated in rooms by themselves, and it is wise to send away children 
who have not been exposed. Morally, parents are criminally negli- 
gent who allow children with whooping-cough to associate with 
healthy children. If the coughing fits are severe or there is fever, 
children should be kept in bed. Usually there is not much fever; 
perhaps an elevation of a degree or two at first, and at times during 
the disease. Otherwise children may be outdoors in warm weather, 



3S6 INFECTIOUS DISEASES 

and in winter on warm quiet days. Sea air is especially good for 
them. 

It is best that the sick should have two rooms, going from one 
to the other, so that the windows in the room last occupied may be 
opened and the room well ventilated. Fresh air at night is especially 
needful, and the patient should sleep in a room which has been 
freshly aired. The temperature should be kept at an even 70° F., 
and the child should not be exposed to draughts. Vaporizing anti- 
septics have been widely used, especially vapocresolin and carbolic 
acid. It is the opinion of the best medical men that pure fresh air is 
of most value and there is a possibility of producing poisoning by 
vaporizing carbolic acid preparations. 

During a fit of coughing, it is well to support the child's head, 
and if he ceases temporarily to breathe, he should be slapped on 
the chest and face with a wet towel. 

Interference with sleep caused by coughing, and loss of proper 
nourishment through vomiting, lead to wasting and debility. Tea- 
spoonful doses of emulsion of cod-liver oil three times daily, after 
eating, are often useful in convalescence, and great care must be 
exercised at this time in order to prevent exposure and pneu- 
monia. 

Change of air and place will frequently hasten recovery remark- 
ably in the later stages of the disease. Vaccines made from the 
killed germs of whooping-cough have been recently injected under 
the skin for the prevention and cure of the disease, with reported 
success. They are particularly useful in preventing whooping-cough 

during epidemics. 

TYPHOID FEVER 

Through ignorance, which prevailed before the more exact meth- 
ods now used for a diagnosis were available, the diagnosis of the 
disease was often doubtful and various terms, such as gastric fever, 
slow fever, nervous fever, some forms of malaria, and moun- 
tain fever, were applied to cases of true typhoid fever. To-day in 
regions remote from medical centers the same mistakes are made, 
and therefore proper precautionary measures are not employed. The 
importance of these may be realized when it is known that the excre- 



TYPHOID FEVER 387 

tions of one typhoid patient in polluting water or food has led to 
thousands of fresh cases and hundreds of deaths. 

Typhoid fever is a communicable disease caused by a germ 
which attacks the intestines chiefly, but also invades the blood, and 
at times other parts of the body. It is characterized by continued 
fever, an eruption on the skin, tenderness and distention of the 
bowels, and often diarrhea. 

It is common in all parts of the world in temperate zones, and 
occurs more commonly from July to December in the north temperate 
zone, and from February to July in the south temperate zone. It is 
most prevalent in the late summer and autumn months, and after a 
hot, dry summer. Persons between the ages of fifteen and thirty are 
more prone to typhoid, but no age is exempt. The sexes are almost 
equally liable to the disease; the robust succumb as readily as the 
weak. One attack usually protects the patient from another, though 
this is not always the case. 

Cause and Mode of Communication. — The typhoid germ is al- 
ways the immediate cause of typhoid fever. It enters the body 
through the mouth, in water, milk, and other foods. The food and 
water is contaminated with the germ through the bowel discharges 
or urine of patients coming into direct contact with them, or by 
the urine or bowel discharges coming indirectly into contact with 
food or water through soiled hands, flies, and dust. 

Water was formerly the chief source of large epidemics of typhoid 
because the water supply was not protected from contamination with 
the excretions of typhoid patients. Thus in Massachusetts before 
public water supplies were in vogue there were ninety-two deaths 
from typhoid fever among one hundred thousand inhabitants annu- 
ally, while thirty-five years later with public water supplies there 
were only nineteen deaths in the same population. 

To-day typhoid fever is rather a disease of the country than 
city. The sanitary preventive measures are enforced to much greater 
extent in the city and the water supply is free from typhoid con- 
tamination. 

Milk to-day is said to be the one most frequent cause of typhoid 
fever in New York City. Milk becomes contaminated with typhoid 



388 INFECTIOUS DISEASES 

germs through polluted water used to wash utensils, and through 
handling of milk by typhoid carriers, by patients, or by those caring 
for patients. The germ multiplies rapidly in milk and may be 
present also in milk products which have not been cooked, as ice 
cream. Proper pasteurization of milk or boiling will make it safe 
to drink. 

Flies are a common medium of communication of the disease by 
first lighting on the nose, mouth, or discharges of typhoid patients 
and then conveying the germs directly to milk, or other food which 
is not cooked before taken. Improper care of excrement and urine, 
with the assistance of flies, has been responsible for the enormous epi- 
demics in military camps. In the Spanish- American war one-fifth of 
all our soldiers in permanent camps contracted the disease. In the 
upper layers of the soil typhoid germs may live for six months 
through the frost and thaws. 

Direct contamination of drinking water by the excretions of 
typhoid fever is prevented by modern sewage systems. It has 
apparently been determined that typhoid germs will live only three 
days in drinking water. Running streams, in quickly carrying the 
germs over long distances in a short time, are much more dangerous 
than still water, which has become polluted at one point. 

Of late years so-called "typhoid carriers" have been found 
responsible for many cases of the fever. These persons are those 
who have had the disease and still carry the germs about in their 
bodies, chiefly in the gall-bladder and bile passages of the liver. The 
genus are constantly being thrown into the bowels with the bile, 
and escaping in the excrement. The hands of the person become 
soiled with the typhoid genus and in turn contaminate food. Thus 
many of the typhoid carriers (who have been discovered) have 
been cooks, and leave a trail of typhoid behind them. In one recent 
case a dairyman was a typhoid carrier for over twenty years, and 
caused an epidemic of hundreds of cases of typhoid fever before the 
source of the infection was traced to him. 

Sewer gas and emanations from sewage and filth cannot in them- 
selves cause typhoid fever. If the germ finds its way into filth 
the latter affords food for its growth and thus is indirectly a dan- 



TYPHOID FEVER 389 

gerous substance, if contaminating food or water, or transmitted 
by flies. 

Oysters growing near the outlets of sewers are also carriers of 
typhoid germs and sometimes are the cause of typhoid fever, if eaten 
raw. Dust is an occasional medium of communication of the germ. 
It is probable, however, that the germ in dust acts only on man by 
contaminating food or drink, and does not enter the body through 
the lungs. It has been suggested that the dust of railroad tracks 
may be a source of danger since human excrement is often deposited 
there by irresponsible men leading a life that renders them subject 
to typhoid fever. 

Ice may harbor the germs and these may withstand freezing for 
a few months before being killed. Epidemics have been traced to 
this source. Clothing, wood, utensils, door handles, etc. (and the 
bodies of the patients themselves), which have been contaminated by 
contact with discharges from patients, may prove media for com- 
munication of the typhoid germ to healthy individuals. 

Typhoid germs escape from those sick with the disease, chiefly 
in the bowel discharges and urine ; sometimes in the sweat, saliva and 
vomited matter. Typhoid fever is wholly preventable and will 
probably be stamped out in time, as has already been done in certain 
regions. 

Period of Development. — From eight to twenty-three days elapse 
from the time of entrance of typhoid germs into the body before the 
patient is taken sick. One attack usually protects a person from 
another, though two or three attacks are not unheard of in the same 
individual. 

Symptoms. — Typhoid fever is subject to infinite variations, but 
it will here be only possible to outline what may be called a typical 
case. In a book of this kind the preliminary symptoms are of most 
importance in warning one of the probability of an attack, so that 
the prospective patient can govern himself accordingly, as in no 
other disease is rest in bed of more value. Patients who persist in 
walking about with typhoid fever for the first week or so of the 
disease are most likely to have serious forms of the fever. 

The average duration of the disease is about one month. During 



390 INFECTIOUS DISEASES 

the first week the onset is gradual, the temperature mounting a little 
higher each day — as 99.5° F. the first evening, 100° the second, 
101° the third, 102° the fourth, 104° the fifth, 105° the sixth, and 
105.5° the seventh. The temperature may never reach over 104° F. ? 
however, and sometimes a lower point. 

In the morning of each day the temperature is usually a degree 
or more lower than that of the previous night. From the end of 
the first week to the beginning of the third, the temperature remains 
at the highest point, being about the same each evening and falling a 
degree or two in the morning. During the third week the tempera- 
ture gradually falls, the highest point each evening being a degree 
or so lower than the previous day, while in the fourth week the 
temperature may be below normal in the morning and a degree or so 
above normal at night. 

After the entrance of typhoid germs into the bowels and before 
the recognized onset of the fever there may be lassitude and disin- 
clination for exertion. The disease begins with headache, backache, 
loss of appetite, sometimes a chill in adults or convulsions in children, 
soreness in the muscles, pains in the belly, nosebleed, and occasionally 
vomiting and diarrhea. There is very often a severe cough, the face 
becomes flushed, the pulse rapid, and the temperature perhaps 100° 
F., and increasing as described above. 

These symptoms are to a considerable degree characteristic of 
the beginning of many acute diseases, but the gradual onset contin- 
uing over days, the constant fever, nosebleed, and looseness of the 
bowels are most suggestive symptoms. Diarrhea occurs in about 
fifty per cent, of cases. Constipation throughout the disease is not 
at all uncommon. If at the end of the first week or ten days of 
fever, pink-red spots like flea bites appear on the chest and belly, to 
the number of two or three, or a dozen, or very numerously, and 
disappear on pressure only to return immediately, the diagnosis of 
typhoid fever is fairly certain. These so-called rose spots often 
appear in crops during the second and third week, remain for a few 
days and depart. 

Headache is apt to be severe for the first week. During the 
second week there is often delirium and wandering at night : the 



TYPHOID FEVER 391 

headache disappears but the patient is stupid and has a dusky flushed 
face. The tongue becomes brownish, its surface cracked, and the 
teeth covered with brownish matter. The skin is generally red, the 
belly distended and tender. There are often from three to ten loose 
bowel discharges daily, of a light-yellow, pea-soup nature, having 
an offensive odor. The pulse ranges from 80 to 120 a minute. 

During the third week, in cases of moderate severity the general 
condition begins to improve with lowering of the temperature, clear- 
ing of the tongue, and less frequent bowel movements. But in severe 
cases the patient becomes weaker with rapid, feeble pulse, ranging 
from 120 to 140. There is a stupor and muttering delirium; twitch- 
ing of the wrists, and picking at the bed clothes, with general trem- 
bling of the muscles in movement, slow, hesitating speech, and 
emaciation, while the urine and feces are often passed unconsciously 
in the bed. 

Occasionally the patient with delirium may require constant 
watching to prevent him from getting out of bed and injuring him- 
self. He may appear insane and patients have not infrequently 
committed suicide while mentally deranged from typhoid fever. 

During the fourth week, in favorable cases, the temperature 
falls to normal in the morning, the pulse is reduced to eighty or 
one hundred, the diarrhea ceases and natural sleep returns. Among 
the many and frequent variations, from the type described, there 
may be a fever prolonged for five or six weeks with a good recovery. 
Chills are not uncommon during the disease, sometimes owing to 
complications. 

Relapse, or return of fever and other symptoms, occurs in about 
ten per cent, of the cases. This may happen more than once, and 
as many as five relapses have been recorded in one patient. A slight 
return of fever for a day or two is often seen, owing to error in 
diet, excitement or other imprudence, after apparent recovery. Pneu- 
monia, perforation of and bleeding from the bowels, are the most 
frequent dangerous complications. 

Unfavorable symptoms are: continued high fever (105° to 106° 
F.), marked delirium, trembling of the muscles in the early stages 
of the disease, and bleeding from the bowels. Also intense and 



392 INFECTIOUS DISEASES 

sudden pain with vomiting, indicating perforation of the bowels. 
The result is more apt to prove unfavorable in very fat patients, 
especially so in persons who have walked about until the fever has 
become high. Bleeding from the bowels occurs in four to six per 
cent, of all cases and causes fifteen per cent, of deaths. Perfora- 
tion of the bowels happens in one to two per cent, of all cases, and 
produces ten per cent, of the deaths. 

Diagnosis. — It is impossible for the layman to positively de- 
termine the presence of typhoid in any given patient, but when 
the symptoms follow the course above indicated a probable diagnosis 
may be made. Unusual types of typhoid fever are among the most 
difficult and puzzling cases a physician has to diagnose. 

Hitherto the doctor could rarely make a positive diagnosis before 
the end of a week or ten days, but there are now tests by which 
an earlier diagnosis may be made. These depend upon finding the 
germ in the blood, by taking a little blood from a vein by means 
of a needle, and also by examination of the blood to determine the 
number of white cells. The finding of the special germ in the 
blood requires the employment of a well-equipped bacteriologist 
and laboratory. The examination of a drop of dried blood, col- 
lected on paper, may determine the presence of the disease after the 
patient has been sick for a week or ten days. Such a specimen 
may be sent by mail for examination. 

Typhoid fever, especially when there are chills, is often mis- 
taken for malaria, when occurring in malarial regions, and may be 
improperly called "typhoid malaria." There is no such disease, 
although rarely the two diseases may coexist in the same person 
at the same time. Examination of the blood will also determine 
the presence or absence of malaria. 

Complications and Sequelae. — These are very numerous. Among 
the former are diarrhea, delirium, mental and nervous diseases, 
bronchitis, pleurisy, pneumonia, ear abscess, perforation of and 
bleeding from the bowels, inflammation of the gall-bladder, disease 
of the heart, kidney, and bladder, and many rarer conditions de- 
pending upon the organ which the germ invades. 

Among the sequelae are boils, baldness, bone disease, painful 



TYPHOID FEVER 393 

spine, and. less commonly, insanity and consumption. While con- 
valescence requires weeks and months, the patient often gains greatly 
in flesh and feels made anew, as in fact he has been to a great extent, 
through the destruction and repair of the tissues. 

Mortality. — The mortality varies greatly under different con- 
ditions, and in different epidemics, and is to some extent altered 
by treatment. The death rate in the 20,000 cases in the Spanish- 
American war was but seven per cent., representing that in the 
best hospitals and in private practice. Osier gives the death rate 
as five to twelve per cent, in private practice, and seven to twenty 
per cent, in hospital practice since the cases are more advanced 
and often poorer subjects in hospitals. 

The chances for recovery are above the average in patients un- 
der fifteen years and between the twenty-second and fortieth years. 

Prevention. — One of the most life-saving discoveries of recent 
years has been the use of a so-called vaccine for the prevention of 
typhoid fever. It is practically a sure preventive if used before ex- 
posure to the disease, and the immunity conferred lastc about two 
to four years, when re-vaccination may be done. 

The vaccine is a watery suspension of five hundred million 
killed germs of the disease which is injected at one dose under 
the skin. Double this dose is injected once on the tenth day after 
the first injection, and again on the twentieth day after the first 
injection, three doses in all, ten days apart. £To dangerous symp- 
toms or deaths have ever resulted, although rarely there is some 
fever, vomiting, and local soreness at the point of injection. There 
is usually not nearly as much discomfort caused by typhoid vac- 
cination as by the ordinary vaccination against smallpox. The 
results of vaccination against typhoid fever are shown in the mobili- 
zation of United States troops on our Mexican border in 1911. 
Among 20,000 thus vaccinated there were only two cases of typhoid 
fever and no deaths. Compare this with our military camp at 
Jacksonville, in the Spanish war, where there were 1,729 cases of 
typhoid fever among 10,759 soldiers, situated in similar circum- 
stances and for the same length of time — four months. 

The record of the Japanese war department shows that among 



394 INFECTIOUS DISEASES 

_ " accinated troops in garrison, there were thirteen sases 
: t phoid among the vaccinated, and 294 cases amoi. i ),245 un- 
vaceinated soldiers at the same time. 

In an addition to this special method of protection against typhoid 
fever there are the general precautions to be observed in guarding 
the attendant against the disease, especially if unvaccinated, and 
in preventing its communication to others. In a time of typhoid 
fever epidemic all water and milk for household uses and drinking 
purposes should be boiled, and all food should be cooked before 
being eaten. Flies should be kept away from all food, from pa- 
tients, and their discharges. 

In the care of the patient the chief means of preventing the 
spread of the disease is by destruction of the germs in the feces 
and urine. The bowel discharges and urine should be mixed with 
three times their bulk of milk of lime (made by mixing one part 
of freshly slaked lime and four parts of water), and should stand 
in this mixture for an hour before being emptied. Instead of milk 
of lime, a solution of carbolic acid (one part in twenty parte : 
hot water) may be used to the extent of three times the bulk of 
urine, and the mixture should stand an hour before being emptied. 
All dishes and eating utensils should be boiled fixe minutes after use 
by the patient, and the bed or body linen should be soaked in the 
carbolic acid solution noted above for two hours before bein^ 
to the laundry. The patient's expectoration should be received on 
old cotton cloth, and should be burnt. The bedpan should always 
contain carbolic acid solution The attendant should always wash 
his hands after touching the patient or objects which have touched 
the patient, or his discharges. 

I: is safer for the nurse to wear a long sleeved apron while 
with the patient, and to wear rubber gloves while handling the 
bedpan or urinal, or cleansing the patient. These should be boiled 
after use. 

A? the germs exist in the saliva, kissi^r the patient should be 
tabooed and even touching the skin may be dangerous since the 
germ sometimes is found in the sweat of the sufferer. Xurses 
and persons below forty-five years old who travel or live in regions 



TYPHOID FEVER 395 

subject to the disease should be vaccinated against typhoid fever. 

Treatment. — There is perhaps no disease in which the services 
of a physician are more desirable or useful than in typhoid fever, 
on account of its prolonged course, and the number of complica- 
tions and incidents which may occur during its existence. 

It is the duty of the physician to report cases of typhoid fever 
to the health authorities and thus act as guardian of the public 
health. If, however, one should happen to have the care of a typhoid 
patient remote from medical aid, it is a consolation to know that 
the outlook is not greatly altered by medicine or special treatment of 
any kind. There have been epidemics in remote parts of this coun- 
try where numbers of persons have suffered from typhoid without 
professional care and yet with surprisingly good results. In an 
epidemic in Canada, twenty-four persons became ill with typhoid 
and received no medical care or treatment whatever, and yet but 
one death resulted. 

Nursing is the main factor and the essentials in treatment are 
rest, diet, and bathing. 

Rest. — Rest to the extent of absolute quiet in bed, at the first 
suspicion of typhoid, is requisite in order to avoid exhaustion and 
the dangers of perforation of the bowels resulting from ulceration. 
The patient should be assisted to turn in bed; he must make no 
effort to rise during the sickness, and should pass urine and bowel 
discharges in a bedpan or urinal under cover. In case of bleeding 
from the bowels the bedpan should not be used but the discharges 
may be received for a time in cloths, without moving the patient. 
It is especially necessary for the attendant to wear .rubber gloves 
when handling the bedpan, body, or clothing soiled wich urine or 
feces, since these hold the germs of the disease. 

Diet. — The diet, until recently, has generally been confined to 
liquids. Dr. Fred. Shattuck, of Boston, has, however, shown that a 
more liberal diet may be given with advantage to the patient. Thus 
milk, broths, purees, strained gruels, ice cream, junket, raw, soft 
boiled or lightly scrambled eggs, raw oysters, rice, macaroni, orange 
or grape juice, and the soft part of baked or stewed apples form a 
suitable diet. Light feeding every two hours, except during a portion 



396 INFECTIOUS DISEASES 

of the sleeping period, is advised — a cup of liquid or some of the 
other articles mentioned. 

Soft custard, egg nog, jellies, coffee and cocoa, white of raw 
egg, strained and diluted with an equal amount of water and 
flavored with a few drops of lemon juice or brandy, or four table- 
spoonfuls of juice squeezed from beef may be used also to add to 
the variety. 

At the end of the first week of normal temperature, finely scraped, 
raw or rare beef, and soft toast may be allowed. These may even be 
given during the disease when fluids are not obtainable or not well 
borne. An abundance of water should likewise be supplied the 
patient throughout the disease to aid in eliminating the poisons pro- 
duced by the germs. The object of the liquid and soft diet is to 
avoid irritation of the ulcerated bowels and prevent bleeding and 
perforation. Milk was formerly the almost sole article of diet, but is 
found not to agree with patients as well as the mixed diet described. 
Some authorities avoid milk altogether. 

Bathing. — The importance of cold water in typhoid fever is enor- 
mous — both in reducing the temperature and in stimulating the 
nervous system and relieving restlessness and delirium. Bathing is 
usually done when the temperature rises above 102° F., and may 
be repeated every two or three hours, if restless ; delirium and high 
fever require it. 

The immersion of patients in tubs of cold water, as practiced 
with benefit in hospitals, is out of the question when trained nurses 
and portable tubs are not available. The patient should have a 
woven wire spring bed and soft hair mattress, over which is laid 
a folded blanket covered by a rubber sheet. Sponging the naked 
body with ice water will suffice in some cases. When the tempera- 
ture is over 102.5° F. the whole body may be enveloped in a sheet 
wet in water at 65° F. The surface of the sheet should then be 
rubbed with lumps of ice, or with cloths wet with ice water, for ten 
or fifteen minutes. Kubbing of the chest and sides of the body is 
necessary during the application of cold to prevent shock. The use 
of a cold cloth on the head and a hot water bottle at the feet, during 
the application of cold, is also desirable. 



TYPHOID FEVER 397 

In children and others objecting to these cold applications, the 
vapor bath is effective. For this a piece of cheese cloth (single thick- 
ness) is wet with water — at a temperature of 100° to 105° F. — 
and is wrapped about the naked body from shoulders to feet, being 
kept continually wet by sprinkling it with water at 98° F. The 
evaporation of water will usually, in fifteen to twenty minutes, cool 
the body sufficiently if the patient is fanned continuously by two 
attendants. 

In warm weather the patient should be covered only with a 
sheet for a while after the bath, which should reduce the tempera- 
ture two to three degrees. A hot water bottle at the feet and a little 
brandy or whisky, given before sponging if the pulse is feeble, will 
generally prevent a chill. Patients should be gently dried after a 
bath and covered with dry bed clothing. The utmost care should 
be taken not to agitate a feeble patient during the process of 
sponging. 

General Care. — The long period in bed favors bed sores. These 
are apt to appear about the lower part of the spine, and begin with 
redness of the skin, underneath which a lump may be felt. Con- 
stant cleanliness and bathing with alcohol diluted with an equal 
quantity of water, and the application of a paste made of nearly equal 
parts of alcohol, castor oil and zinc oxid to the reddened area will 
prevent their occurrence. Moving the patient, so he will lie on his 
side, and keeping the bed clothes smooth under him together with 
the use of a rubber ring air cushion, under the base of the spine, 
are all serviceable. 

Brandy or whisky diluted with water are valuable in severe cases 
with muttering delirium, dry tongue, and feeble pulse. They are 
not called for before the end of the second week, and not in mild 
cases at any time. A tablespoonful of either, once in two to four 
hours, is usually sufficient. 

Pain and distention of the abdomen are relieved by applying 
a pad over the whole front of the abdomen — consisting of two layers 
of flannel wrung out in a very little hot water containing one tea- 
spoonful of turpentine — and should be covered by a dry flannel 
bandage wrapped about the body. The avoidance of milk in this 



398 INFECTIOUS DISEASES 

condition is also advisable. In case of great distention two table- 
spoonfuls of castor oil will act favorably in many cases. 

The mouth, teeth, and tongue should be carefully cleaned three 
times a day with a swab of absorbent cotton wet in a solution of 
boric acid (as much as water will dissolve). The lips may be kept 
moist by rubbing glycerin on them. Spraying the throat three times 
daily with Dobell's solution will prevent the complication of ear 
abscess. 

Diarrhea is checked by giving one-quarter of a level teaspoonful 
dose of bismuth subcarbonate with a teaspoonful of paregoric, 1 once 
every three hours if there are more than four loose movements in 
twenty-four hours. Constipation is relieved by the daily use of an 
injection of soapsuds to which may be added an ounce or two of 
glycerin. 

Bleeding from the bowels is treated by keeping the patient ab- 
solutely quiet, by giving lumps of ice by the mouth, and withholding 
nourishment for thirty-six hours. An icebag should always be kept 
continuously over the abdomen. Fifteen drops of laudanum * should 
be given to adults. No sponging or bathing should be done. 

As a matter of routine, patients may be allowed to sit up during 
typhoid fever after a week of normal temperature has passed. Solid 
food is not to be allowed until two or three weeks, after the fall of 
fever, and then very gradually avoiding all coarse, uncooked vege- 
tables and fruit. 

EPIDEMIC CEREBROSPINAL MENINGITIS 

Mode of Infection. — Meningitis is an acute infectious and con- 
tagious disease, occurring both in isolated cases and in epidemics. 
Sudden changes in temperature and humidity, by producing colds, 
tend to favor the occurrence of the disease — for the meningitis 
germs gain entrance into the blood through the nose and throat, and 
apparently more readily in persons who already have catarrh of 
these parts. Moreover, the germ of meningitis itself causes colds, 
so that a cold mav be the beginning of meningitis. 

1 Paregoric and laudanum can only be bought on a doctor 's prescription. 



EPIDEMIC CEREBROSPINAL MENINGITIS 399 

In epidemics there are great numbers of healthy persons who 
carry about the meningitis germs in their noses and throats with- 
out having the disease themselves. These so-called "carriers" may 
number from ten to thirty times the actual number of meningitis 
cases. Among those in close contact with meningitis patients, as 
many as seventy to eighty per cent, may become healthy carriers 
and so pass along the germs to others, who may in turn become car- 
riers or may succumb to the disease. 

The contagiousness is comparatively slight, and doctors and 
nurses do not fear meningitis — in some hospitals there has never 
been a case from contact. It may be compared to pneumonia in 
this respect, but in epidemics the danger of contagion is greater. 
Only a small percentage of carriers take the disease, but they are the 
chief means of spreading it. 

"While the germ generally dies in the throat of patients and car- 
riers within a few weeks, patients may occasionally become carriers 
of the meningitis germ for months or years. These are especially 
dangerous, because they spread the disease far and wide — often 
into foreign countries. 

Development.— The average time elapsing between the entrance 
of the meningitis germ into the throat and the development of the 
first symptom varies from one to five days. It may happen that 
the germs lurk in the throat a long time before they get into the 
blood. This may account for the very wide variations in the time 
occasionally observed after exposure, before the development of 
the disease. 

Symptoms. — There are many variations of this disease, but only 
the more common symptoms will be described. The patient may 
have been suffering from a cold, when he is suddenly attacked 
with chills and fever, severe headache, and pains all over the body, as 
in grippe, and also with dizziness and violent vomiting. 

There are apt to be restlessness and irritability; the pupils are 
dilated ; cold sores or fever blisters appear about the lips and chin. 
There may or may not be fever ; there is tenderness about the angle 
of the jaw, and soreness is felt on tapping the head. This is the 
stage corresponding to the entrance of the germs into the blood. 



400 INFECTIOUS DISEASES 

It may last but a few hours or a day, and then appears the second 
stage, produced by the pressure of increasing fluid under the mem- 
branes surrounding the brain and spinal cord. 

This often begins with convulsions; the patient is extremely 
sensitive to noise and light ; the mind wanders, or there is a mild 
delirium or stupor. The pain in the head, back of the neck, spine, 
and leg is severe ; the neck becomes rigid ; and the head is drawn 
back. A young patient may often be lifted from the bed by raising 
the head alone. 

If the finger nail is drawn firmly over the skin of the patient a 
marked red line remains. The face is often congested and bluish, 
the breathing is irregular; the pulse is slow or rapid. There is 
frequently partial deafness. A sign peculiar to the disease is seen 
when the thigh is bent on the abdomen by an attendant and an attempt 
is then made to straighten out the leg. The leg cannot be brought 
to much more than a right angle. There are occasional cases in 
which all the early symptoms appear, only to disappear within forty- 
eight hours, whereas in other cases death occurs within a few hours. 

The course of the disease is very irregular. With the modern 
serum treatment recovery is often complete in a few days, or a week 
or two. Without this treatment cases mav dras: alone; for weeks or 
months with great emaciation, and patients are often apparently both 
deaf and blind, the limbs are drawn up, and the joints are frequently 
stiff and swollen. Headache, stupor, convulsions, and vomiting are 
common, with irregular fever. 

The diagnosis between the epidemic cerebrospinal meningitis and 
other non-contagious forms is too difficult for the layman to attempt. 
A non-contagious form due to tuberculosis is the most common, but 
is seen more often in infants under two years of age. It is only 
when meningitis is epidemic that the layman would be likely to 
make a correct diagnosis from the description herein given. It 
is of the utmost importance to secure the best medical aid at the 
earliest moment so that the doctor may withdraw a sample of the 
fluid within the spinal canal, from which a positive diagnosis may 
be made, and thus the earliest treatment be given. 

Treatment. — The method of injecting serum in the cure of epi- 



EPIDEMIC CEREBROSPINAL MENINGITIS 401 

demic meningitis, introduced by Simon Flexner, has had as re- 
markable a life-saving effect in this dreaded disease as antitoxin in 
diphtheria. 

Flexner 's serum is prepared by injecting subcutaneously into 
horses first the products of the living meningitis germs, and follow- 
ing this the germs themselves, in gradually increasing doses. The 
horses do not acquire the disease, but are made somewhat sick by the 
injections, and gradually become immune to meningitis. After four 
months they are bled, and the clear portion of the blood which sepa- 
rates out on standing (serum) is used for treatment of human beings 
with meningitis. 

First the fluid caused by the disease is drawn off from the spinal 
canal through a hollow needle, introduced at the lower part of the 
back of the patient, and then from one teaspoonful to two table- 
spoonfuls of horse serum, prepared as above, is injected in its place. 
The injections should be made daily for four days. When don© 
properly the injections cause little pain, and in 1500 done by Soph- 
ian, there was not a single bad result. 

Withdrawing the fluid from the spinal canal relieves the pressure 
on the brain and spinal cord, to which many of the worst symptoms 
are due, and also permits of the examination of the fluid which 
shows the gravity of the disease. The injection of the serum kills the 
germs in the spinal fluid, or more precisely allows the cells of the 
body to kill them. 

In the late epidemic in Texas, 1,394 cases of meningitis were 
treated with serum with a death rate of thirty-seven per cent. ; 
while the death rate in 562 cases without serum was seventy-seven 
per cent. Early and skillful treatment is the most successful. Soph- 
ian treated 161 cases with serum, and lost but 15.5 per cent. No 
other treatment is of much value. 

Prevention. — In epidemics, those exposed to the disease should 
first gargle the throat and spray the nose with salt and water, and 
follow this with a spray and gargle of hydrogen peroxid (1 part) 
mixed with water (5 parts). If this is done three times daily the 
germs will disappear from the throat of carriers within three days, 
in ordinary cases, to ten days in the most resistant. Also, if exposed 



402 INFECTIOUS DISEASES 

persons take ten grains of urotropin in a glass of water three times 
daily, it. being a strong antiseptic, will tend to protect them. 

Vaccination with the dead germs of meningitis, as for typhoid 
(described in this chapter) and given in the same way, appears to 
protect persons for a year against the disease. It is the best method 
of prevention we have, and is without danger. Headache, fever, and 
vomiting rarely follow vaccination the first few hours. 

The United States Public Health Service has issued the follow- 
ing rules : 

Information Eegardixg Prevention of Meningitis 

1. The germ which causes epidemic cerebrospinal meningitis has 
been found only in the human body. 

2. Healthy persons may carry the germ in their nose and throat 
without ever developing the disease. Such persons are known as car- 
riers. There are about ten carriers to every case of meningitis in an 
infected locality. 

3. The measures for lessening the spread of the germs of this dis- 
ease are as follows : 

(a) The nose and throat should be kept clean. For this purpose 
cleansing sprays may be used. 

(b) Careful attention to personal hygiene, mainly cleanliness. 
Avoid chilling of the body and other depressing influences. Dress to 
meet the changes of weather. 

(c) Avoid close contact with persons. Healthy persons who are 
carriers may innocently transmit the germs, which may be in their nose 
and throat, by coughing, sneezing, kissing, talking, etc. 

(d) Children should not use articles which may have come in eon- 
tact with the mouths of others, such as pencils, particles of food, drink- 
ing cups, handkerchiefs, and the like. 

(e) Cleanliness of premises and free ventilation of houses are nec- 
essary. The germ of this disease is easily killed when exposed to drying 
and sunlight. Hence it is important to thoroughly ventilate and expose 
to sunlight all occupied rooms. 

(/) The disease is not carried by clothing, merchandise, etc. 

(g) Persons suffering with "colds'' — that is. nasal catarrh, sore 
throat, or cough — should be careful in the presence of others, and seek 
early medical attention and relief. 

Handkerchiefs wet with discharges from the nose or throat should 
be disinfected bv boiling in water. 



CHAPTER IX 

INFECTIOUS DISEASES (Continued) 

DISEASES DUE SOLELY TO THE BITES OF MOSQUITOES- 
MALARIAL AND YELLOW FEVER 

Malaria, including chronic pernicious, intermittent, remittent, typhomala- 
rial, and black-water fever. Yellow fever. 

MALARIA 

Cause and Mode of Communication. — Malaria is a communi- 
cable disease characterized by attacks of fever occurring at certain 
intervals, and due to a minute animal parasite which inhabits the 
body of the mosquito, and is only communicated to man by the 
bites of this insect. 

In accordance with this definition, malaria is not a contagious 
disease in the sense that it is acquired directly from the sick. It is 
derived from the bites of certain kinds of mosquitoes and can be 
contracted in no other way, despite the many notions to the con- 
trary. 

Mosquitoes in their turn acquire the malarial parasite by biting 
human beings suffering from malaria. It thus becomes possible 
for one malarial patient, coming to a region hitherto free from the 
disease, to infect the whole district with malaria, through the medium 
of mosquitoes. 

While the parasite-bearing mosquito is the only cause of malaria, 
certain circumstances are requisite for the life and growth of the 
mosquito and parasite; these are moisture and proper temperature, 
— the latter should not average less than 60° F. for the growth of 
the mosquito. The malarial parasite also will not grow if the climate 

403 



4:04: 



INFECTIOUS DISEASES 



be too cold. The malarial parasite only exists in man and the 
mosquito, so far as is known. 

Development. — Malaria is prevalent in temperate climates, in 
the summer and autumn months particularly, less often in spring and 
very rarely in winter. It is common in the tropics and subtropics all 
the year round, but more frequently in the spring and fall of these re- 





Fig. 54. — A. Anopheles Mosquito. B. Culex or Common Mosquito. (After Doty 

"The Mosquito.") 



gions. The older ideas that malaria was caused by something arising 
in vapors (malaria literally means bad air) from wet soil, marshes, or 
bodies of water, by contamination of drinking water, by night air, by 
sleeping outdoors or on the ground floors of houses, are only true 
in so far as these conditions favor the presence of malarial mosquitoes. 
Those digging in moist soil, as in the making of railroads, sewers, 
ditches, and canals, are especially subject to malaria because of espe- 
cial exposure to mosquitoes. So excesses, exposure, and alcoholism 
predispose to the disease by weakening the natural resistance. 

The negro possesses some immunity to malaria. 

Two essentials are requisite for the existence of malaria in a 



DISEASES DUE TO BITES OF MOSQUITOES 405 

region — the presence of the particular mosquito and the actual infec- 
tion of the mosquito with the malarial parasite. The Anopheles is 
the only genus of mosquito known to convey the malarial parasite 
to man. Fifty or more species have been described. 

The more common house mosquito of this country is of the genus 
Culex (Fig. 54B). The Anopheles (Fig. 54A) may usually be distin- 
guished from it by its mottled wings and, when on a wall or ceiling, it 
sits with the body protruding at an angle of 45° from the surface, 
with its hind legs hanging down or drawn up against the wall. 

In the case of the Culex the body is held parallel with the wall, 
the wings are usually not mottled, and the hind legs are carried 
up over the back. The Culex does not convey malaria. 

When a mosquito infected with the malaria parasite bites man, 
the parasite enters his blood along with the saliva that anoints the 
lancet of the mosquito. The parasite is one of the simplest forms 
of animal life, consisting of a microscopical mass of living, moving 
matter which enters the red blood cell of man, and there grows and 
undergoes changes. After a variable time it multiplies by breaking 
into a number of still smaller bodies which represent a new genera- 
tion of young parasites. 

It is at that stage in the development of the malarial parasite in 
the red blood cells of man, when the segment breaks through the 
blood cells into the liquid portion of the blood, that the attack of chills 
and fever occurs. What causes the malarial attack at this point is 
unknown, unless it be that the parasites produce a poison at the 
time of their segmentation. Between the attacks of chills and fever, 
in malaria, there is usually an interval of comparative health lasting 
some hours or days, and corresponding to that period occupied by 
growth of the new crop of parasites, up to that time when they again 
burst open the red cells and escape into the liquid portion of the 
blood, and again poison the patient. 

This interval between the attacks of malaria depends upon the 
time occupied by the growth of the particular kind of parasites 
infecting the human blood. The common form of malaria (tertian) 
is caused by a parasite requiring forty-eight hours for its development. 
The malarial attacks produced by this parasite then occur every 



406 INFECTIOUS DISEASES 

other day, at which times the parasite undergoes segmentation. 
However, an attack may occur every day when there are two sepa- 
rate groups of these parasites in the blood, the time of birth of one 
set of parasites happening one day, with an accompanying malarial 
attack, and that of the other group coming on the next, so that 
between the two there is a daily birth of parasites and a daily attack 
of malaria. 

In cases of malaria caused by one group of parasites the times 
of attack may vary on different days. In the worst types of malaria 
the parasites do not all go through the same stages of development 
at the same time, as is commonly the case in the milder forms seen 
in temperate regions, so that the fever — corresponding to the time 
of birth of a new crop of parasites — occurs at irregular intervals. 

In a not uncommon type of malaria (quartan) the attacks occur 
every third day, with two days of freedom from fever. Different 
groups of parasites causing this form of malaria and inhabiting the 
same person will have different times of segmentation, and thus give 
rise to variation in the times of attack. An attack may even occur 
on two successive days with a single day of intermission. 

Malaria is very widely distributed, and is much more severe in 
tropical countries and in the warmer parts of temperate regions. In 
Xew England the disease has been prevalent along the valleys of the 
Connecticut and Charles Rivers, but is much less frequent at pres- 
ent. So also in the cities of Xew York, Philadelphia and Baltimore, 
it is less common than formerly, and is of a comparatively mild type. 
More severe forms prevail along the Gulf of Mexico and the banks 
of the Mississippi and its branches, especially in Mississippi, Texas, 
Louisiana, and Arkansas, but even here it is less fatal and wide- 
spread than formerly. In Alaska, throughout the Xorthwest, and on 
the Pacific coast it is practically unknown, while it is but slightly 
prevalent in the region of the Great Lakes, as about Lakes Erie and 
St. Clair. 

There is no malaria in the St. Lawrence basin. In many parts 
of the Southern states malaria is common but less so than formerly. 
In the West Indies severe forms occur, except in Havana. The 
Atlantic Central American coast has been called "the white man's 



DISEASES DUE TO BITES OF MOSQUITOES 407 

grave/' on account of malaria, but Colonel Gorgas has largely elimi- 
nated it from the Panama Canal Zone. 

In the northern three-fourths of South America malaria abounds. 
T n Africa severe forms are found everywhere except in the Sahara 
and in the lower part. Malaria is indigenous in the Far East, in 
India, Burma, Assam, and the East Asiatic coast, Japan, Asia Minor 
and the East Indies. In Europe malaria is most frequent in Italy, 
Hungary, Greece, the Balkans, and lower Russia. 

Symptoms.— Fever occurs from one and one-half to fifteen days 
after entrance of the parasite into the blood. About two billion 
parasites in the blood are required to produce symptoms. It often 
happens that the parasite remains quiescent in the blood without 
being completely exterminated after recovery from an attack, only 
to grow and cause a fresh attack a month or two after the first, 
unless treatment with quinin has been thoroughly carried out. Cer- 
tain symptoms give warning of an attack, as headache, lassitude, 
yawning, restlessness, discomfort in the region of the stomach, and 
nausea or vomiting. 

The attack begins with a chilliness or creeping feeling, or there 
may be so severe a chill that the patient is violently shaken from 
head to foot and the teeth chatter. Frequently the chill is absent, 
and after a preliminary stage of dullness, there is fever followed by 
sweating. This is called "dumb ague." 

Chills are not commonly seen in children under six, but an attack 
begins with uneasiness, the face looks pinched, the eyes sunken, 
the lips, tips of the fingers, and toes blue, and there is dullness and 
often nausea and vomiting. Then, instead of a chill, the eyelids 
and limbs begin to twitch and the child goes into a convulsion. While 
the surface is cold during a chill, the temperature, taken with the 
thermometer in the mouth or bowel, often reaches 102° to 105° F. 

The chill lasts from a few minutes to an hour, and then it passes 
away, the face becomes flushed and the skin hot. There is often a 
throbbing headache, thirst, and sometimes a mild delirium. The 
temperature at this time, when the patient feels intensely feverish, 
is but little higher than during the chill. The fever lasts three 
or four hours, in most cases, and gradually declines, as well as the 



408 INFECTIOUS DISEASES 

headache and general distressing symptoms, to disappear in an hour 
or two, when the patient often sinks into a refreshing sleep. 

The attacks come on usually between ten a. m. and three p. m. 
and last ten hours, — less often from four to forty-eight hours. 

Such attacks more commonly occur every day, every other day, or 
after intermissions of two days. Rarely do attacks come on with 
intervals of four, five, six or more days. In severe cases the inter- 
vals may grow shorter, in mild cases, longer. In the intervals the 
patient generally feels well, unless the disease is of exceptional 
severity. There is entire freedom from fever in the intervals, except 
in the grave types common to the tropics. 

Chronic Malaria 

Irregular and Severe Forms. — Chronic malaria occurs in those 
who have lived long in malarial regions and have suffered repeated 
attacks of fever, or in those who have not received proper treatment. 
It is characterized by a general enfeebled state, the patient having a 
sallow complexion, cold hands and feet, and temperature below 
normal, except occasionally, when there may be slight fever. 

When the condition is marked, there are breathlessness on slight 
exertion, swelling of the feet and ankles, and "ague cake," — that is, 
enlargement of the spleen, shown by a lump felt in the abdomen 
and extending downward from beneath the ribs on the left side. 
There may be severe bleeding from the stomach and into the eyes. 

Among the unusual forms of malaria are: periodic attacks of 
drowsiness without chills but accompanied by slight fever (100° to 
101° F.) ; periodic attacks of neuralgia, as of the face or chest or as 
sciatica; and periodic "sick headaches." These may take the place 
of ordinary malarial attacks in malarial regions, and are cured by 
ordinary malarial treatment. 

It has been found by examination of the blood that from five to 
thirty per cent, of persons in malarial districts are carriers of the 
parasites without having any symptoms of malaria themselves. The 
carriers are a menace to the community by infecting mosquitoes. 

Remittent Form, sometimes called Bilious Fever — Typho- 
malarial Fever. — This type of severe malaria occurs sometimes in 



DISEASES DUE TO BITES OF MOSQUITOES 409 

late summer and autumn in temperate climates, but is seen much 
more commonly in the southern United States and in the tropics. It 
begins often with lassitude, headache, loss of appetite, and pains in 
the limbs and back, a bad taste, and nausea for a day or two, fol- 
lowed by a chill, and by fever ranging from 101° to 103° F., or more. 

The chill is not usually repeated, but the fever is continuous, often 
suggesting typhoid fever. With the fever there is flushed face, occa- 
sional delirium, more often a drowsy state, and vomiting of bile. 
After twelve to forty-eight hours the fever abates, but the tempera- 
ture does not usually fall below 100° F., and the patient feels 
better but not as well as in the ordinary form of malaria where the 
fever disappears wholly between the attacks. After an interval 
varying from three to thirty-six hours, the fever rises again and the 
more severe symptoms reappear. In this way the disease continues, 
there never being complete freedom from fever — the temperature 
sometimes rising as high as 105° to 106° F. In some cases there is 
nosebleed, cracked tongue, brownish deposit on the teeth, and a 
delirious or stupid state, as in typhoid fever, but the distention of the 
belly and the diarrhea and rose spots are absent. 

Typhomalarial fever is not an entity but the two diseases, typhoid 
fever and malaria, may occur in the same individual at the same 
time. This indeed frequently happened in our soldiers coming from 
the West Indies in the Spanish- American war, but it is an extremely 
uncommon event in the United States. 

Pernicious Malaria 

This is a very grave form of the disease. It is rarely seen in 
temperate regions, but often occurs in the tropics and subtropics. 
It may follow an ordinary attack of chills and fever, or come on 
very suddenly. After a chill the hot stage appears, and the patient 
falls into a deep stupor or unconscious state, with flushed face, noisy 
breathing and high fever (104° to 105° F.). Wild delirium or con- 
vulsions afflict the patient in some instances. The parasites actually 
plug the blood vessels of the brain in these cases. The attack may 
last from six to twenty-four hours, from which the patient may re- 
cover, only to suffer another like seizure, or he may die in the first. 



410 INFECTIOUS DISEASES 

Another form resembles true cholera, and is peculiar to the 
tropics. In this there is violent vomiting, watery diarrhea, cramps 
in the legs, cold hands and feet, and collapse. Sometimes these 
attacks begin with a chill, but fever, if any, is slight, although the 
patient complains of great thirst and inward heat. The pulse is 
feeble, the breathing shallow, but the mind remains clear. Death 
often occurs in this, as in the former type of pernicious malaria, yet 
vigorous treatment with quinin, iron, and niter will frequently cure 
either form. 

Black Water Fever. — A third form of pernicious malaria is one 
with bleeding from various parts of the body. Thus in black water 
fever the urine becomes very dark, owing to the escape of blood 
into it. There are two varieties of this form: One is apparently 
simply a very severe type of malaria in which great numbers of red 
cells of the blood are destroyed while the coloring matter is elimi- 
nated by the urine. 

At other times, in addition to the infection with the malarial 
parasite, the action of quinin aids in the destruction of the red blood 
cells, together with the influence of the lowered resistance produced 
by previous malaria and the poison set free in the blood by a re- 
newed malarial attack. This form is seen in the Southern states 
and in the tropics, especially Africa and South America. There 
have been several hundred cases of black water fever during the 
building of the Panama Canal. There may be chilliness and irregular 
fever before the voiding of dark urine, and jaundice is also usually 
present. It may be safer not to give quinin in this form of malaria. 

Diagnosis. — To the well-educated physician is now open an exact 
method of determining the existence of malaria, and of distinguishing 
it from all other fevers, by the examination of the patient's blood 
for the malarial parasite or plasmodium — its presence or absence 
deciding the presence or absence of malaria. For the layman the 
following points are offered: first the occurrence of attacks of chills, 
fever, and sweating, remembering that the chills and sweating may be 
frequently wanting. The fever more often begins in the early part 
of the day, whereas most common fevers are at their height in the 
late afternoon. 



DISEASES DUE TO BITES OF MOSQUITOES 411 

The intermittency of attacks of fever in a person coming from 
a malarial region is most suggestive of malaria. Intermittency of 
attacks of chills, fever, and sweating is not confined to malaria, how- 
ever, as these symptoms often occur in blood poisoning. The qninin 
test is the best. If a fever is not cured by a daily dose of twenty to 
thirty grains of quinin — continued for four days — the disease is not 
malaria, except in the tropics when larger doses may be required 
(Laveran). This treatment will do no harm even if the disease is 
not malaria. Many cases of malaria will recover without the use of 
quinin. 

Prevention.- — Since the French surgeon, Laveran, discovered the 
parasite of malaria in 1880, and Manson, in 1896, presented irref- 
utable evidence for all time that the mosquito is the medium of 
communication to man, the way for the extermination of the disease 
has been plain. "Mosquito engineering" has attained a recognized 
place. Malaria has been eliminated from Havana by the efforts of 
the United States Army surgeons, following American occupancy. 
Colonel Gorgas has attained worldwide fame for transforming the 
"white man's grave" (and black too) at Panama, into a salubrious 
region with a death rate resulting from disease lower than that of 
any civilized country. In the French occupancy of the Canal Zone 
the mortality reached 177 per thousand, while under Colonel Gorgas 
it has fallen to 7.5 per thousand chiefly through the elimination of 
malarial deaths. 

The means required for the prevention of malaria include the 
following: destruction of the abodes of mosquitoes in marshes, 
ponds, and pools by draining, filling, and planting eucalyptus, corn 
and sugar cane (the work should be done by immunes or by whites 
who work under careful medical supervision) ; the application of 
crude petroleum or kerosene to the surface of stagnant water and the 
placing of fish in such ; on large bodies of water, only the edge may 
be thus treated, where most of the immature mosquitoes are to 
be found ; for streams a constant drip may be used ; open water barrels 
and tanks must be abolished; the protection of persons from 
mosquito bites is obtained by proper screening of the house, and by 
the use of a screened porch, while the screening of the bed is use- 



412 INFECTIOUS DISEASES 

less because people protrude their limbs in sleep. Persons should not 
go into the open unscreened air at or after nightfall, when the pests 
are most in evidence. Dwellings on high ground are less liable to 
mosquitoes. All Anopheles found in dwellings should of course be 
killed. 

Adults in malarial regions should take two grains of quinin, in 
capsules, three times daily at meals (from April to November), to 
kill any malarial parasites which may invade the blood, ancf at the 
same time they should observe the measures suggested to avoid ma- 
laria (p. 414). Patients recovering from malaria should take pro- 
longed treatment, as advised below, renewing it each spring and fall 
for some years. 

A malarial patient, and those in malarial regions who harbor 
the parasite without themselves suffering, should be protected from 
the bites of mosquitoes since these insects may convey the disease 
broadcast. A malarial patient, or carrier of the parasite, is thus a 
menace to the whole community unless he observes sanitary pre- 
cautions. 

Treatment. — The patient should remain in bed and take only 
liquid and soft food, as milk, soups, soft egg, cereal, and toast. At 
night three grains of calomel should be given in one dose to an adult 
and followed, on waking in the morning, by a tablespoonful of Epsom 
salts in a whole glass of water. 

Quinin is the remedy in malaria and is one of the few specifics 
in medicine, killing the malarial parasite in the blood without harm- 
ing the patient. Quinin is capable of doing no harm unless used 
in large doses for months, despite the popular prejudice against it. 
The subjects of malaria escape the evil effects of quinin which 
are felt by persons with other diseases. Some ringing in the ears, 
and feeling of fullness in the head, and slight deafness may occur 
after the larger doses. When quinin does not agree with patients 
euquinin may be used. Quinin produces the acme of its effect in 
malaria when there is the greatest amount in the blood at the time 
of the attack, when the spores or immature parasites escape from 
the red blood cells into the liquid portion of the blood. A dose 
of twenty grains of quinin taken just before the time for an attack 



DISEASES DUE TO BITES OF MOSQUITOES 413 

may prevent another. Qninin is often adulterated and should be 
obtained at a reliable drug house. Neither pills nor tablets are suit- 
able as they sometimes pass through the stomach and bowels undis- 
solved. The drug should be taken dissolved in water, with syrup 
of orange peel, and a few drops of dilute sulphuric acid (which dis- 
solves it), or in capsules or starch wafers. 

Children take the solution with syrup readily. When the drug 
is vomited it may be given in double the dose, dissolved in half a 
pint of water, as an injection into the bowels, thrice daily. Infants 
of a few months may be treated by rubbing an ointment, thirty grains 
of quinin in one and one-half ounces of lard, well into the skin of 
the armpit and groins, night and morning. Children under the 
age of two can best be given quinin in suppositories (little conical 
bodies containing two grains each of quinin in cocoa butter), one 
being introduced into the bowel night and morning. 

Half a teaspoonful of sodium bromid may be taken in one-half 
glass of water and hot drinks and hot water bottles, with warm cov- 
ering, may be used during the chill, while an icecap to the head and 
cold sponging of the naked body will afford comfort during the hot 
stage. In the severe form with unconsciousness, the icecap to the 
head and the use of the cold bath, with vigorous friction with a 
rough cloth over the whole body, are valuable. 

The routine method of using quinin follows: A dose of ten 
grains of quinin sulphate should be taken three times daily for three 
days, or as long as attacks persist, then a dose of three grains should 
be taken five times daily for two weeks ; and finally three grains daily 
for the rest of the month of treatment will, in many cases, complete 
a cure. If the larger doses of quinin cause much ringing in the 
ears or deafness, it will be found that sodium bromid dissolved in 
a whole glass of water and taken at the same time as the quinin, 
in twice the dose, will correct this trouble. To children may be given 
a daily amount of quinin equal to one grain for each year of the 
child's age. 

In the severe forms of remittent and pernicious types of malaria 
it may be necessary for the patient to take thirty grains of quinin 
in a single dose for some time every three days, but as digestion and 



414 INFECTIOUS DISEASES 

absorption may be poor, the drug should be taken in solution as 
the bisulphate of quinin with five grains of tartaric acid. The injec- 
tion of the muriate of quinin and urea under the skin, in ten 
grain doses three times daily, will often give the best results in severe 
and persistent cases. This should be carried out by a doctor. 

In chronic malaria a capsule containing two grains of quinin 
sulphate, one-thirtieth grain of arsenic trioxid, and two grains of 
reduced iron, should be taken three times daily for several weeks. 

Change of climate is also of great value. 

In black water fever the use of quinin is to be withheld, un- 
less parasites are found in the blood, in which case it is to be em- 
ployed. 

In the United States Health Keport of March 27th, 1914, it is 
stated that in malarial states the disease can usually be prevented 
by the taking of from five to seven grains of quinin sulphate daily 
in tablet form' for adults ; and six grains daily of quinin tannate, in 
two grain tablets with chocolate three times daily, for children ; from 
April to November. It states further that these doses can produce 
no harm, although there may be a few cases of malaria from the 
existence of the parasite in the blood from the year before. In addi- 
tion, the house should be thoroughly screened ; brush or weeds cut 
about dwellings ; and near-by pools should be oiled with crude petro- 
leum, or better drained or filled. 

• 

YELLOW FEVER 

Yellow fever is a disease of the seacoast in tropical and subtropical 
countries characterized by fever, jaundice, and vomiting (in severe 
cases of blood), and caused by a special germ communicated to man 
solely through the agency of bites of a special mosquito — Stegomyia 
fasciata. The special germ has not, however, been isolated. 

Yellow fever has always been present in Havana, Cuba, Vera 
Cruz, and other Spanish- American ports; also on the west coast of 
Africa. 

It is frequently epidemic in the tropical seaports of the Atlantic, 
in North and South America, and Africa. There have been in the 



DISEASES DUE TO BITES OE MOSQUITOES 415 

past numerous epidemics in the southern, and occasional ones in the 
northern Atlantic seacoast cities of the United States. The last 
epidemic was small and occurred in 1899, in the Soldiers' Home in 
Hampton, Ya. 

Barely has the disease been introduced into France, Great Britain, 
and other parts of Europe, and it has never spread there except in 
Spanish ports. 

The disease is one requiring warm weather, for a temperature 
under 75° F. is unsuitable to the growth of the mosquito harboring 
the yellow fever germ. The germ does not live long in the patient, 
and he can communicate the disease to mosquitoes for only three 
days. 

Yellow fever prevails in crowded and unsanitary parts of sea- 
coast cities, to which it is brought on vessels by contaminated 
mosquitoes or yellow fever patients from the tropics. It is then a 
ship disease. 

Havana has always been the source of infection for the United 
States, but since the disease has been eradicated through the work 
of Dr. Walter Beed and associates of the American Army of Oc- 
cupation, that danger has been removed. Yellow fever is not at 
all contagious in the sense that a healthy person can contract the 
disease by contact with a yellow fever patient, or with his dis- 
charges from the stomach, bowels, or elsewhere, and it is only com- 
municated to man by the bite of the particular kind of mosquito 
harboring the yellow fever germ in its body. 

Both these facts have been incontestably proved by brave volun- 
teers (Dr. B. B. Cooke and two privates), under the command 
of Major Walter Beed, U. S. A., who submitted to sleep for twenty- 
one days on clothes soiled by the discharges from patients dying of 
yellow fever, and escaped the disease. While others, living in un- 
contaminated surroundings, permitted themselves to be bitten by in- 
fected mosquitoes and promptly developed yellow fever. Dr. James 
Carroll recovered from a severe attack, but Dr. J. W. Lazear died 
from the inoculation. These martyrs to science gave to mankind the 
greatest medical discovery ever made in America, save that of 
ether anesthesia. 



416 INFECTIOUS DISEASES 

Development. — Usually from three to four days elapse after 
a person has been bitten by an infected mosquito before the develop- 
ment of the first symptoms — from fourteen hours to five days and 
seventeen hours, more precisely. 

A period of two weeks must pass after the appearance of a 
single first case in a region before the next arises. This follows 
because a mosquito, after biting a patient, cannot convey the germ 
to another person for a period of twelve days, and two or three 
days more will be required before the patient will suffer any ill 
effects. 

Symptoms. — During the night or morning the patient has a 
chill or feels chilly, and has discomfort and tenderness in the stom- 
ach, with sometimes nausea and vomiting. There is pain in the 
forehead and eyes, and often in the back and legs. The face is 
flushed, the eyes bloodshot and perhaps slightly yellow, the eyelids 
and lips somewhat swollen, and the expression is a mixture of pain, 
restlessness, and confusion, suggesting intoxication. 

The whites of the eyes and skin may become tinged with yellow 
within thirty-six hours, but usually this is not marked until the 
third to the fifth day. This jaundice is one of the distinguishing 
features of the disease, but is often absent in children and in fifty 
per cent, of cases which recover. The presence of albumin in the 
urine is another important point. This occurs from the first to the 
third day usually. Boiling the urine in a glass tube causes the 
formation of a white cloudiness due to albumin. 

The pulse is another peculiar feature of the disease. In the 
beginning the pulse ranges from 100 to 130, while the temperature 
varies from 101° to 104° or 105° F. The fever continues for 
several days — except in mild cases — but the pulse falls. For in- 
stance, on the third day the temperature may rise a degree, to 103° 
F., while the pulse falls teu to twenty beats or so at this time, and 
may even be normal — between 70 and 80. 

In some cases after the second day the patient appears to im- 
prove, and the pains and fever lessen. This is called the deceptive 
stage and, after a day or two, the patient becomes worse again — 
vomits blood, and bleeds from the nose, gums, tongue, throat, bowels, 



DISEASES DUE TO BITES OF MOSQUITOES 417 

womb — and has hiccough, pain, and tenderness in the stomach, and 
marked jaundice. 

The dreaded "black vomit" more often begins with increased 
vomiting on the fourth to the sixth day. This presents the appear- 
ance of coffee grounds or is like ink. The substance vomited is 
altered blood from the stomach, and the same may be seen issuing 
from the bowels. 

While a serious sign, it does not by any means presage a fatal 
ending. The action of the kidneys is usually suppressed and the 
urine scanty. It is extremely important to pay regard to this 
feature because failure of the patient to pass a proper amount of 
urine (a quart or more in twenty-four hours) calls for prompt action 
to avert fatal poisoning from retained waste matter in the blood. 

The course of the disease varies greatly. In children — espe- 
cially of the Creoles — it is frequently so mild as to pass unnoticed. 
It is probable that most of the immunes in affected regions are 
those who have previously had exceedingly mild attacks. In adults 
the fever may last only a few hours or two or three days, with 
gradual recovery from the various symptoms — yellowness of the 
skin lasting some time. This is not seen readily during the stage 
of fever when the surface is reddened, but at that time may be de- 
tected by pressure on the skin for a moment, when the skin will 
present a yellow hue on removing the finger before the blood returns. 

Then in others, following abatement of symptoms for two or 
three days, fever again returns with vomiting or black vomit, and 
death occurs from suppression of urine with delirium, convulsions, 
or stupor, or the patient may begin to recover again after a few days. 
Relapses and various complications are frequent. 

Mild fever, slight jaundice, and absence of bleeding are favor- 
able signs; black vomit, high fever, and passage of little urine 
are unfavorable. The death rate is very variable in different epi- 
demics and among different classes: anywhere from 10 to 85 per 
cent. The better results occur in private practice among the well- 
to-do classes. The subjects of alcoholism or poverty are apt to 
succumb. 

Diagnosis. — The essential features of yellow fever are the 



418 INFECTIOUS DISEASES 

flushed, seemingly semi-intoxicated appearance, the jaundice, the 
albumin in the urine, vomiting, black vomit, tenderness over the 
stomach, the slowing pulse, and bleeding from bowels or mouth. 

Prevention. — Yellow fever, like malaria, is a preventable disease, 
and will — in a not remote day — be only a matter of historic interest. 

Colonel W. C. Gorgas, U. S. A., following in the footsteps of 
Major Reed (who demonstrated the mosquito the cause of yellow 
fever in Havana, in 1900), succeeded in 1901 in ridding Havana 
of these pests and of yellow fever. 

Havana, a city of 250,000, with 6,000 births and 20,000 suscep- 
tible persons coming in every year, had been a hotbed of yellow fever 
continuously for one hundred and thirty years. From 500 to 1,600 
persons had died of it each year in that city. Colonel Gorgas, by 
screening patients, so that they could not be bitten by mosquitoes, 
by killing infected mosquitoes, and by destroying the breeding places 
of the Stegomyia mosquitoes by the screening of water barrels and 
other receptacles and treating drains, sewers, etc., with kerosene, 
succeeded in eradicating yellow fever from Havana so that the last 
case occurred in September, 1901, with not a single case in the fol- 
lowing year. The city has been free from the disease since, except 
for a slight return. 

The Americans occupied the Canal Zone in 1904, and it took 
sixteen months to abolish the disease there, and it has not reap- 
peared. 

When a new case is brought to a community, spread of the 
disease is prevented by keeping mosquitoes away from the patient 
(living or dead), while personal freedom from yellow fever may 
be secured by avoiding mosquito bites through protection by screens 
indoors, by remaining indoors after the sun has gone down, and by 
the use of oil of pennyroyal or spirit of camphor on exposed parts 
of the face, hands, and ankles while outdoors. 

Treatment. — There is, unfortunately, no special cure known for 
yellow fever such as we possess in malaria. The patient should be 
well covered and surrounded with hot water bags during the chilly 
period. 

Hot mustard foot baths give much relief in headache, and both 



DISEASES DUE TO BITES OF MOSQUITOES 419 

the bath and patient should be surrounded by blankets. It is 
advisable to give a good purge the first day, but not after the second 
day. A single dose of ten grains of calomel for an adult, followed 
in ten hours by a tablespoonful of Epsom salts in a glass of water; 
or four tablespoonfuls of castor oil, may be taken. To relieve 
the headache and pains twenty grains of sodium salicylate in cap- 
sules, followed by a glass of water, may be given every three hours 
for three or four doses. The drinking of much water is imperative, 
and Sternberg found that a solution of one hundred and fifty grains 
of sodium bicarbonate (ordinary cooking or baking soda) in a quart 
of water is of great value if taken to the amount of three tablespoon- 
fuls every one-half hour. Charged, cold Vichy water may be used 
in place of this. 

Vomiting may be allayed by giving only cracked ice by the mouth 
with a tablespoonful of iced champagne once in half an hour, or 
by giving a single tablet of one-fourth grain of cocain once in two 
or three hours. When the patient cannot take water freely, on 
account of vomiting, a pint of warm water containing a level tea- 
spoonful of salt should be injected slowly into the bowel night and 
morning, so as to be retained and absorbed, to increase the action of 
the kidneys. 

A mustard paste (made by mixing one part mustard and three 
parts of flour with warm water) spread between two layers of 
soft cotton, as big as the hand, applied over the stomach, will also 
aid in arresting vomiting. 

If there is much tenderness and pain in the stomach, mustard 
foot baths (one tablespoonful to the gallon) are also advised. Cold 
sponging, packs or baths are best for fever. {See Typhoid Fever.) 
The bowels should be moved daily by injection of warm soapsuds. 
The patient should not rise from bed, but use a bedpan. !No food 
whatever should be given the first tw T o days, only when the appetite 
is returning, and any indiscretion in diet may cause a relapse of 
the disease, as in typhoid fever. The diet should consist of milk, 
diluted with an equal amount of carbonated Vichy water, or with 
plain water, broths, and gruels, and only soft food, as cereals, milk 
toast or soft egg, should be given until ten days after cessation of 



420 INFECTIOUS DISEASES 

the fever. Iced champagne, as advised above, or two teaspoonful 
doses of whisky in a little ice water at frequent intervals, aid in 
supporting the strength. 

The black vomit may be arrested by one-fourth teaspoonful 
doses of tincture of chlorid of iron in four tablespoonfuls of ice 
water every hour after vomiting. 



CHAPTEE X 
THE NOSE, MOUTH, AND THKOAT 

Nosebleed. Cold in the head. Foreign bodies in the nose and throat. Sore 
mouth or stomatitis. Canker, smoker's tongue, white patches in the 
mouth. Eoul breath. Diseases caused by enlarged tonsils. Inflamma- 
tion of the gums and decayed teeth. Ulcerated teeth. Toothache. 
Mouth breathing, including enlarged tonsils, adenoids, and nasal ob- 
structions. Tonsillitis. Quinsy. Diphtheria. Laryngitis. Croup. 

NOSEBLEED 

Nosebleed is caused by blows or falls, or more frequently by 
picking and violently blowing the nose. The cartilage of the nasal 
septum, or partition which divides the two nostrils, very often be- 
comes sore in spots, owing to irritation of dust-laden air, and these 
crust over and lead to itching. Then "picking the nose" removes 
the crusts, and frequent nosebleed results. These scabs or crusts 
can usually be prevented from forming by keeping carbolized vase- 
lin in the nose. 

Nosebleed also is common in both full-blooded and anemic per- 
sons ; in the former because of the high pressure within the -blood 
vessels, in the latter owing to the thin walls of the arteries and 
capillaries which readily rupture. 

Nosebleed may be a warning, a remedy, or a disease. It may 
be a warning in conditions of high blood pressure, as in those past 
middle age with hardening of the arteries, and in those having 
disease of the kidneys, heart, liver, and lungs. It may be a rem- 
edy in threatened apoplexy from high blood pressure by lowering 
the pressure through the escape of blood. Nosebleed is a disease, 
or rather a sign of disease, when due to growths or ulcerations in 
the nose, or conditions noted above, to disease of the blood fol- 

421 



422 THE NOSE, MOUTH, AND THROAT 

lowing typhoid fever and eruptive fevers, and when occurring in 
families of "bleeders." 

The bleeding comes from one nostril only, and is a general 
oozing from the mucous membrane, or more commonly flows from 
one spot on the septum near the nostril, the cause of which we 
have just noted. The blood may spout forth in a stream, as after 
a blow, or trickle away drop by drop, but is rarely dangerous ex- 
cept in infants and aged persons with weak blood vessels. The usual 
position assumed by the person with nosebleed is that of stooping 
over a basin — the worst position possible. This prevents blood 
from returning to the heart by compression of veins in the neck. 
The patient should sit with the head absolutely erect and hold a 
bowl under the chin to catch the blood. Clothing about the neck 
should be loosened. 

If the nosebleed comes on at night during sleep, the blood may 
flow into the stomach without the patient's knowledge, and on being 
vomited may suggest bleeding from the stomach. 

Treatment. — The avoidance of excitement and of blowing the 
nose, hawking, and coughing will assist recovery. There is no cause 
for alarm in most cases, because the more blood lost the more read- 
ily does the remainder clot and stop bleeding. As the blood gen- 
erally comes from the lower part of the partition separating the 
nostrils, the finger should be introduced into the bleeding nostril 
and pressure made against this point, or the whole lower part of 
the nose may be simply compressed between the thumb and fore- 
finger. If this does not suffice a lump of ice may be held against 
the side of the bleeding nostril, and another placed in the mouth. 
The injection into the nostril of ice water containing a little salt 
is sometimes very serviceable in stopping nosebleed. Blowing the 
nose must be avoided for some time after the bleeding ceases. 

If none of these methods arrest the bleeding the nostril must be 
plugged. A piece of clean cotton cloth, about five inches square, 
should be pushed gently but firmly into the nostril with a slender 
cylinder of wood about as large as a slate pencil and blunt at the 
end. This substitute for a probe should be pressed against the 
center of the cloth, which folds about the stick like a closed umbrella, 



COLD IN THE HEAD 423 

and the cotton pressed into the nostril in a backward and slightly 
downward direction, for three inches, while the head is held erect. 
Then pledgets of cotton wool are packed into the bag formed by 
the cotton cloth after the stick is withdrawn. The mouth of the 
bag is left projecting slightly from the nostril, so that the whole 
can be withdrawn in twenty-four hours; or strips of soft cotton, 
linen or cheese cloth may be pushed into the nostril until they plug 
it up, leaving the ends hanging for removal. It is best to saturate 
all the material for plugging the nostril with hydrogen peroxid, if 
it is at hand, for this better than any other remedy causes the 
blood to stop, by making a large, firm clot in the nose. If the blood 
begins to show through the plug the end of the latter should be 
wet with Monsel's solution to clot the blood. 

The bleeding nostril may be more readily plugged by simply 
pressing into it little pledgets of cotton with a slender stick, but it 
would be impossible for an unskilled person to get them out again, 
and a physician should withdraw them within forty-eight hours. 
Occasionally when plugging the nostril does not stop the nosebleed, 
it is necessary for a doctor to plug the nose from behind in the 
throat. 

COLD IN THE HEAD 

Causes. — As in many other germ diseases, there is a predis- 
posing cause and a true cause. Thus one of the commonest pre- 
disposing causes of colds is prolonged exposure to cold or wet, espe- 
cially when the body is overheated. This chilling of the surface 
of the skin leads to congestion in the nose, the blood vessels dilate 
and become paralyzed, and the secretions are altered. It is at this 
stage that the altered secretions offer a suitable medium for the 
growth of germs — the true cause — and the cold becomes a germ 
disease unless dissipated at the start. 

The germs most often responsible for colds are those causing 
inflammation in wounds (streptococci and staphylococci), and one 
or two others, while, if the cold becomes chronic, the germs of 
pneumonia are practically always present in the discharge. The 
germs of certain special diseases are found in the nose of patients, 
and in these disorders cold in the head is often the first symptom 



424 THE NOSE, MOUTH, AND THROAT 

to be noted, as is the case in measles, influenza, and in cerebrospinal 
meningitis. 

Colds are contagious and therefore healthy persons, especially 
children, should not sleep in the same room or be closely associated 
with patients suffering from head colds. In some institutions for 
children, tradespeople are not permitted to enter the house in order 
to avoid the introduction of colds. 

Among the predisposing causes, other than exposure to cold, are 
the following: The wearing of overwarm underclothing indoors 
in cold weather is a prolific cause of colds, while on the other hand, 
the taking of a daily cold bath in a very warm room, on rising, is 
one of the best preventives of colds. The wearing of extra clothing 
on the chest is not preventive of colds — quite the contrary. 

The best place for a chest protector is on the soles of the feet, 
which means that the feet cannot be kept too dry and warm in cold 
weather. 

The dry heat of houses in winter is provocative of colds in dry- 
ing the nose and throat and preventing the normal discharges from 
washing away dust and germs, and in causing irritation of the nasal 
mucous membrane by dried secretion and crusts. The evaporation 
of water into the house should be provided for in connection with 
all modern heating apparatus. In fact, moisture in the air is of as 
much importance as fresh air. Recent research has shown that good 
ventilation does not mean rapid removal of waste products and 
expired air: it shows that air becomes oppressive when too hot, dry, 
and still. Ventilation means sufficient coolness, moisture and mo- 
tion of the air. The same air that seems unfit for breathing will 
become respirable if the temperature is lowered and the air kept 
in motion by fans, without the introduction of fresh air. 

Dust favors colds, especially in houses and cities, in being germ- 
laden and irritating. Various chronic diseases are responsible for 
frequent colds, as chronic catarrh, obstruction from deformities of 
the partition between the nostrils, polypi, and — the most common 
cause of all in children — adenoid growths. Any lowering of the 
general vitality predisposes to colds. 

The prevention of colds naturally means the removal of the sev- 



COLD IN THE HEAD 425 

eral causes noted. Colds might be included among the infectious 
diseases, as measles, etc., but they differ from these, however, in 
not being due to a special germ but to one of several special germs. 
They may be epidemic and occur more often in spring and fall when 
changes in weather are most marked. 

Symptoms. — Colds often start with a feeling of dryness and 
soreness in the upper and back part of the throat for a day or so 
before the nose grows dry and sneezing begins, with swelling of 
the mucous membrane and fullness and obstruction in the nose. 
The discharge from the nose is first watery, but after two days it 
becomes thick. There may be severe pain in the forehead and in 
the upper front teeth. 

Chilliness, pain in the lower part of the back and legs, fever 
(101°-102° E.), with malaise and loss of appetite may form a part 
of severe colds. Obstruction in the nostrils may make breathing 
difficult — a serious matter in infants, especially if nursing. A cold 
will last from two to three days to as many weeks. If frequently 
repeated, a chronic nasal catarrh may result. 

While complete recovery from acute colds is the rule, yet cer- 
tain complications threaten. Extension of the cold, or infection, 
downward into the throat leads to laryngitis with hoarseness; ex- 
tension into the bronchial tubes and air cells of the lungs means 
bronchitis or pneumonia. Even more common are complications 
in the head, as extension of the inflammation up the eustachian 
tubes which lead, one from either middle ear to either side of 
the upper part of the throat — back of the nasal passages. This may 
eventuate in abscess of one or both ears, rupture of the ear drums, 
and escape of pus. 

Again, extension of the inflammation into the numerous air 
cavities of the head (sinuses) connected with the nasal passages 
gives rise to what is known as sinusitis. In this, persistent and 
severe headache in and about the eyes or forehead, and even nausea 
and vomiting, may occur. The pain grows worse on stooping (in- 
crease of blood in the head), and there may be some tenderness on 
pressing the points marked in Figure 55 at and over the site of 
the frontal sinuses. Abscess of the frontal sinus is rare, as the 






THE NOSE, MOUTH, AXD THBOAT 




inflammatory secretions usually drain through the natural passages 
connecting with the nose. 

Acute inflammation in the cavities inside the bones of the face 
(antrum ' may be caused by a cold in the head, and abscess may 
result from closing of the natural opening from the antrum into 
the nose and retention of secretion. 

There is then neuralgia of the side of the face and head, tender- 
ness over the antrum, and often pain in 
chewing, as the first and second back 
teeth have fangs reaching up into the 
antrum. More commonly., inflammation 
and abscess of the antrum are caused by 
closure of the opening into the nose 
through chronic catarrh, or inflammation 
extending from decay of the teeth men- 
tioned, and antrum disease is then a slow 
chronic process. 

Treatment. —Severe, persistent head- 
ache in Golds suggest sinusitis. To arrest 
a cold in the head the writer has found 
nothing so successful as a 12 per cent, 
freshly made solution of argyrol. The patient, on the first sugges- 
tion of cold in the head or throat, should hold the head well back and 
drop a medicine dropperful of this solution slowly into each nostril 
twice daily. If the head is held back a minute or two the solution 
will not run out of the nose but down the throat, when it may be 
swallowed, as it is harmless for adult or infant. One or two such 
applications will often cure a beginning cold. When the solution 
can be given by an attendant it is better for the patient to lie flat on 
ck and have the solution dropped into the nose by the attendant. 
The solution stains badly, and clean old cotton cloths should be used 
for handkerchiefs. The stains on clothing may instantly be removed 
by soakinsr in a solution made by dissolving a corrosive sublimate tab- 
let in half a pint of water. 

In addition to this, the patient should take a warm bath, and 
drink two or more glasses of hot lemonade before going to bed. and 



Fig. 55. — F. Site of Frontal 
Sixrs. A. Site of Axtea 
of HiGHiiOBE. Pressure on 
the skin over these points 
r__ : ; ' show tenderness in in- 
flammation (Sinusitis) in 
these cavities in the skull. 



COLD IN THE HEAD 427 

move the bowels the following morning with a Seidlitz powder, or 
a tablespoonful of Epsom salts in a tumbler of water on rising. 
Even if the cold is not treated in the beginning it is still well to 
try the argyrol solution a few times. 

If the cold is severe, the patient will recover more quickly, and 
the danger of complications will be minimized, by staying in bed. 
The internal use of drugs is of little value unless the patient re- 
mains in bed. Then the following prescription may be taken, espe- 
cially if there is much headache. 

Phenacetin 10 grains 

Sodium salicylate 30 " 

Monobromated camphor 6 " 

Mix and make six capsules. 

One of these capsules should be taken hourly as long as they 
last. If the secretion is profuse and the nose is obstructed the nasal 
passages should be sprayed night and morning with a solution made 
from Seiler's tablets, by dissolving one in an atomizer two-thirds 
full of hot water. The solution should be used as hot as can be read- 
ily borne. A coarse spray is best, so that the entire contents of 
the atomizer may be used each time. By enlarging the opening in 
the hard rubber tip of the atomizer with a red-hot needle this may 
be accomplished. 

Then every three hours a medicine dropperful of the following 
solution should be dropped into each nostril with the head thrown 
back. 

Iodin 2 grains 

Menthol 30 " 

Camphor 30 « 

Albolene 2 ounces 

Mix. Drop into nostrils as directed. 

Should the cold become chronic, or colds become frequent, it is 
probable that some condition exists in the nose which can best be 
treated locally by a doctor. 

The following tonic is useful in persistent colds: 



428 THE NOSE, MOUTH. AXD THROAT 

Quinin sulphate 45 grains 

Reduced iron 1 drachm 

Strychnin sulphate 1 grain 

Arsenic trioxid y 2 grain 

Mix and make 30 pills. 

Directions : One pill three times daily after meals. 

The treatment of infants with colds consists in the giving of 
one teaspoonful of castor oil at the onset and keeping the child 
outdoors as much as possible, unless the child has fever or the 
weather is very inclement. If there is fever the child should be 
kept in bed, and five to ten drops of sweet spirit of niter should 
be given in a teaspoonful of sweetened water every three hours. 
At the beginning of the cold ten drops of the argyrol solution, 
noted above, should be dropped into the nostrils twice, about twelve 
hours apart, and after this a solution of boric acid, sixteen grains, 
in one ounce of albolene, should be dropped into the nostrils every 
three hours, using about one-half a dropperful in each nostril. 

To prevent colds in infants a washcloth should be wrung out 
in cold water and the skin of the back and chest, down to the waist, 
should be rubbed briskly with it each morning, followed by a dry rub. 

FOREIGN BODIES IN THE NOSE 

Children often put foreign bodies, as shoe buttons, beans, and 
pebbles, in their noses. They may not tell of it, and the most 
conspicuous symptoms are the appearance of a thick discharge 
from one nostril, having a bad odor, and some obstruction to breath- 
ing on the same side. If the foreign body can be seen, the nostril 
on the unobstructed side should be closed and the child made to 
blow out of the other one. If blowing does not remove the body 
sneezing may — by making the patient inhale snuff through the 
other nostril, or by tickling it. 

FOREIGN BODIES IN THE THROAT 

These may arise from food, as fish bones, particles of meat, 
or hard bodies, such as pins, marbles, coins, needles, toothpicks, and 
false teeth, may be held in the mouth and be drawn in with the 



SORE MOUTH— INFLAMMATION OF THE MOUTH 429 

breath. If the foreign body cannot be removed with the finger in 
the mouth and is obstructing the breathing, the patient should be 
turned upside down and be slapped on the back. If there is great 
difficulty in breathing, artificial respiration should be performed 
until a doctor arrives. 

SORE MOUTH— INFLAMMATION OF THE MOUTH 

(Stomatitis) 

There are various forms of inflammation of the mouth, gen- 
erally dependent upon the entrance of germs, associated with in- 
digestion, teething, or general weakness following some fever or 
other disease. 

Unclean nipples of the mother, or unclean bottles allow entrance 
of germs, and are frequent causes in infants. Irritation of a sharp 
tooth, rubbing the gum, food that is too hot, or too vigorous cleansing 
of the mouth, may start the disease. Some chemicals, especially 
mercury, improperly prescribed, produce the disease. The germs 
may gain admission in some cases in impure milk. Inflammation 
of the mouth is essentially a children's disease, only the ulcerated 
form being common in adults. 

Symptoms. — In general, the mouth is hot, very red, dry, and 
tender; the child is fretful and has difficulty in nursing, often 
dropping the nipple and crying; the tongue is coated, and there 
may be fever and symptoms of indigestion, as vomiting. Some- 
times the disease occurs during fevers; later in the course of the 
disorder the saliva often runs freely from the mouth. 

Simple Form. — In the simple form there are only redness, swell- 
ing, and tenderness of the inside of the mouth. The tongue is at 
first dry and white, but the white coating comes off, leaving it red 
in patches. After a while the saliva becomes profuse. There may 
be lumps under the jaw or swollen glands. 

The treatment consists in washing the mouth often in ice water 
containing about one-half drachm of boric acid to four ounces of 
water, by means of cotton tied on a stick, and holding lumps of 
ice in the mouth wrapped in the corner of a handkerchief. It is 
well also to give a teaspoonful of castor oil. 



430 THE XOSE, MOUTH, AND THEOAT 

Aphthous Form. — In this there are yellow-white spots or little 
blisters, surrounded by a red zone, which break and leave little de- 
pressions or ulcers, on the inside of the cheeks and lips, and on the 
tongue and roof of the mouth. These occur in crops and last from 
ten to fourteen days. The disease is often preceded by vomiting, 
constipation, and fever, with pain in the mouth and throat, and is 
accompanied by lumps or swelling of the glands under the jaw 
and in the neck. 

The treatment consists in the use of castor oil, and swabbing 
the mouth several times a day, after each feeding, with boric acid 
solution, as advised before, or better with permanganate of potash 
solution, using ten grains to the cup of water. One should be 
careful not to rub off the tender membrane. If any raw spots 
appear in the mouth, from the running together of several blisters, 
they should be touched with a five per cent, solution of silver nitrate 
with a pledget of absorbent cotton wound on a toothpick. 

Thrush (Sprue). — This form is due to the growth of a special 
fungus (like that of yeast) in the mouth, occurring as white spots 
on the inside of the cheeks, lips, tongue, and roof of the mouth, 
looking like flakes of curdled milk. There are also symptoms of 
indigestion, as vomiting, diarrhea, and colic. The disease is con- 
tagious. Sometimes ulcers or sore depressions are left in the 
mouth, and in weak children — in whom the disease is apt to occur 
— the result may be serious, and a physician's services are demanded. 

The treatment consists in applying saleratus and water (one 
teaspoonful in a cup of water) to the whole inside of the mouth, 
between feedings, with a camel's-hair brush or with a soft cloth. 
A dose of castor oil is also desirable, and great care regarding 
cleanliness of the mouth and sterilizing of the bottles and nipples 
should be exercised. 

Ulcerous Form.' — This fomi does occur in children, but may 
attack persons of all ages. It is often seen following measles and 
scarlet fever, and in the poor and ill-nourished, and after the un- 
wise use of calomel. Want of care of the teeth appears to favor 
the disease, as it occurs in those with decayed teeth and having 
accumulations of tartar on them. It is sometimes epidemic in 



SORE MOUTH— INFLAMMATION OF THE MOUTH 431 

camps, jails, and poorly conducted public institutions. The mar- 
gins of the gums, where they join the teeth on both the upper and 
lower jaw, first become red, and swollen, and bleed easily. Then 
ulcers form on the gums which are covered with a grayish or yel- 
lowish white membrane which cannot readily be removed. While 
the tongue, inside of the cheeks and lips are swollen and painful,, 
they are not usually ulcerated. Matter, or pus, forms between 
the teeth and the gum, and the mouth has a foul odor. The glands 
under the jaw and in the neck are enlarged, feeling like tender 
lumps, saliva flows freely and chewing becomes very painful. In 
severe cases the gums may become destroyed and eaten away by 
the ulceration, and the bone of the jaw be diseased and exposed. 

In the graver cases, it may become necessary to remove dead 
bone and teeth, and the very dangerous form next described may 
sometimes follow. It will be seen that it is a disease requiring 
skilled medical attention. The treatment consists in using, as a 
mouth wash and gargle, Dobell's or Seller's Solution, or a solution 
of chlorate of potash (fifteen grains to the ounce) every two hours. 
Cases usually last at least a week. Potassium chlorate is very 
successful in curing the disease when given internally: three grains 
for a child of two, ten grains for a child of twelve, and twenty grains 
for adults, in plenty of water three times daily. 

Gangrenous Form (Noma). — This is a rare and fatal form of 
inflammation of the mouth, and occurs in children w T eak and debili- 
tated from other diseases, as from the contagious eruptive fevers, 
chronic diarrhea, and scurvy. • It is seen more often in hospitals 
and is contagious. A foul odor is noticed about the mouth, in which 
an ulcer on the gum or inside of the cheek will be seen. The cheek 
swells tremendously, with or without pain, and becomes variously 
discolored — red, purple, black. 

The larger proportion of patients die of exhaustion and blooof 
poisoning within one to three weeks, and the only hope is through 
surgical interference at the earliest possible moment. 



432 THE XOSE, MOUTH, AND THEOAT 

CANKER 

A canker is a small, shallow, yellow ulcer, appearing on the 
inside of the lips or beneath the tongue during some disorder of 
the digestion. It is very tender when touched, and renders chew- 
ing or talking somewhat painful. 

Treatment. — The treatment consists in touching the ulcer care- 
fully with the point of a wooden toothpick which has been dipped 
in pure carbolic acid (a poison), and then rinsing the resulting 
white spot and the whole mouth very carefully with water, so as 
not to swallow any of the acid. 

SMOKER'S TONGUE 

{Leukoplakia) 

This disorder consists of ivory or bluish-white, slightly raised 
patches (or small white spots) upon the upper surface or sides of 
the tongue. Occasionally these white patches are seen on the sides 
of the cheeks, roof of the mouth, gums, and inside of the lips, while 
the tongue is free. The patches are permanent, usually give rise 
to no sensation, and cannot be easily scraped off. They may inter- 
fere with chewing and speaking. 

While the disease occurs most often in heavy smokers, it also 
is observed in others. Temporary white patches are seen on the 
tonsils and palate and back of the mouth, cheeks, and tongue in 
diphtheria and in syphilis. When no fever is present, such a con- 
dition would suggest syphilis. In smoker's tongue the chief ulti- 
mate danger is of ulceration and cancer. 

Treatment. — The treatment is rather unsatisfactory and should 
be undertaken by an expert skin specialist. Hot food and smoking 
are to be forbidden. Sharp teeth should be put in order. 

FOUL BREATH 

This is a general disease, often occurring as a result of chronic 
disorders of the mouth and throat, as chronic tonsillitis, and* in- 
flammation of the gums or Riggs 3 disease, or decayed teeth. 

To test for the presence of the first two diseases one may rub 



MILD SORE THROAT 433 

firmly on the tonsils with the tip of the finger and smell the finger ; 
in the case of Riggs' disease, one may draw a thread up between 
the teeth and then under the edge of the gums in various places 
and then smell the thread. A foul odor in either case would in- 
dicate the presence of disease. Such conditions are accompanied by 
the presence of putrefactive and pus-forming germs which, with 
their poisons, may enter the blood and produce the most grave dis- 
orders. The medical authorities of the world regard poisoning from 
chronic mouth disorders as having the most far-reaching conse- 
quences. 

Thus, chronic rheumatism, appendicitis, gall-bladder inflamma- 
tion, pleurisy, diseases of the kidney, heart, nervous system, and 
fatal anemias, are all thought to be caused by chronic inflammation 
of the gums and tonsils. (See Chronic Rheumatism.) 

Foul breath frequently arises from other causes, as indigestion 
and inflammation of the mouth (stomatitis), while many diseases 
of the nose occasion it. 

Osier warns us that most persons of middle age or over have a 
certain amount of inflammation of the gums (Riggs' disease or pyor- 
rhea alveolaris) and that every one should go to the dentist once 
a month for cleaning of the teeth, removal of tartar, and preven- 
tion of pus pockets in the gums; also that one should not hesitate 
to speak to friends who have a disagreeable breath and point out 
to them its significance. The brushing of the teeth at bedtime and 
after breakfast, and the use of an antiseptic mouthwash afterwards 
(Dobell's or Seller's solution, to be had in tablet form, or glycothy- 
mol), are also of much value. For special treatment of chronic ton- 
sillitis and Riggs' disease, see special chapters under these headings. 

MILD SORE THROAT 

(Acute Pharyngitis) 

The milder sore throat is commonly the beginning of an ordi- 
nary cold, although sometimes it is caused by digestive disorders, 
gout, and foreign bodies in the throat. Exposure to cold and wet 
is, however, the most frequent source of this form of sore throat. 

Soreness, dryness, and tickling first call attention to the trouble, 



434 THE NOSE, MOUTH, AND THEOAT 

together with a feeling of chilliness and, at times, slight fever. 
There may be some stiffness and soreness about the neck, owing to 
swelling of the glands. If the tongue is held down by a spoon 
handle, the throat will be seen to be generally reddened, including 
the back, the bands at the side forming the entrance to the throat 
at the back of the mouth, and the uvula or small, soft body hanging 
down from the middle of the soft palate at the very back of the 
roof of the mouth. The tonsils are not large and red nor cov- 
ered with white dots, nor is the fever high, as in tonsillitis. The 
throat may be so sore as to be intensely painful, especially during 
swallowing. The voice is husky and there is a feeling as if there 
were a foreign body in the back of the throat, which keeps the 
patient continually hawking and spitting. The surface of the throat 
is first dry and glistening, and streaked with stringy, sticky mucus. 

Treatment. — The disorder rarely lasts more than a few days. 
The bowels should be moved in the beginning of the attack by some 
purgative — as two compound cathartic pills or three grains of calo- 
mel — and a spray from an atomizer containing Seller's or Dobell's 
solution, or simply warm water in which one teaspoonful of salera- 
tus to the cupful is dissolved, should be used frequently. 

Troches, each containing one and one-half grains of guaiac and 
one-fourth grain of tannic acid, are also very useful. One should 
be dissolved in the mouth hourly. Gargles are not so efficient as 
the spray from an atomizer. The sucking of gelatin lozenges 
(zymol) and hoarhound and lemon drops will afford some relief. 
Smoking must be discontinued while the throat is sore. 

ULCERATED TOOTH 

(Alveolar Abscess) 
An ulcerated tooth means inflammation of the root of a tooth 
with the formation of matter or pus between the root and the bone 
in which it is placed — in other words the socket. The pain is 
intense because the pus is confined under pressure in this unyield- 
ing; cavity of the bonv socket. There mav be no cavitv in the tooth, 
but the tooth is commonly dead or the nerve is dying, and the tooth 
is frequently darker in color. 



ULCERATED TOOTH 435 

How shall we determine which is the ulcerating tooth if there 
is severe toothache ? A severe, persistent pain in a single tooth 
which has no cavity means an ulcerated tooth in most cases. The 
pain is not always felt in the one tooth but may seem to be in several. 
By tapping the various teeth in turn with a piece of metal, as the 
handle of a table knife, special soreness will be found in the ulcerated 
tooth. Then there will usually be swelling about the gum nearest 
the affected tooth, and often in biting, pain will be felt in the diseased 
tooth because it projects lower than its fellows. 

Results of Alveolar Abscess — If the inflammation develops 
into abscess and formation of pus in the socket of the tooth, various 
results are likely to occur. The face swells as well as the gum, the 
swelling in the face being most in the region of the diseased 
tooth. 

The pus may escape into the mouth alongside of the tooth, with 
relief of pain, and only some soreness of the tooth and slight swell- 
ing of the gum may remain. If this does not occur, besides the 
swelling of the face, there may also be swelling of the gland, as a 
lump under the back of the lower jaw, from an ulcerated tooth in 
either the upper or lower jaw. 

Another common course is for the pus to break out through the 
gum near the ulcerated tooth with relief from pain, but a little 
hole in the gum may remain, discharging pus at times and connected 
with the decayed tooth. This gets stopped on occasions and abscess 
may recur. The hole or sinus is usually on the outer side of the 
tooth and perhaps one-quarter of an inch distant from it. Then, 
if the abscess goes on without interference, it may break out on the 
cheek, or beneath the jaw through the skin, leaving a bad scar; 
sometimes the glandular lump under the jaw becomes so inflamed 
that abscess forms in it. If the abscess about the tooth is left to 
itself too long, there may be sufficient inflammation to cause death 
of a small area of the jawbone about the tooth socket. Then, even 
though escape of pus gives relief from pain, there will remain some 
swelling of the gum about the tooth and a hole in the gum dis- 
charging pus indefinitely. 

Such a chronic inflammation may rarely give rise to a malignant 



436 THE NOSE, MOUTH. AND THEOAT 



tumor from constant irritation. Abscess of the first two upper 
back teeth may involve the antrum. 

Treatment. — In threatened abscess of a tooth, that is in severe 
toothache where there is no cavity in the tooth, one may secure 
relief sometimes by painting the gum about the diseased tooth with 
tincture of iodin on a camel's hair brush, or by applying a tooth- 
ache plaster (sold by all druggists) to the gum, about once an hour. 
Then the patient may lie with the painful side of the face on an 
ice bag. The pain may subside, owing to the fact that the trouble- 
has been only congestion, or to the unnoticed escape of pus through 
a minute opening in the gum. 

If, however, the inflammation continues, the pain becomes in- 
tense and throbbing, and rest and sleep impossible, there may be 
fever and chills from a slight degree of blood poisoning. 

The dentist is, of course, the proper person to consult in all 
cases of toothache. The tooth should be treated at once by removal 
of the filling, if there is one, and by the use of a local anesthetic, 
cleaning out, and disinfecting its cavity. Filling is postponed 
until the soreness about the tooth disappears, or until the nerve is 
killed, etc. The immediate removal of the tooth will give the most 
instantaneous and effective relief and prevent the complications noted 
above, by affording free escape of the pus. 

Many dentists refuse to pull an ulcerated tooth but tell the 
patient to return when the trouble has subsided. This is bad advice, 
and there is not the slightest objection to extracting an ulcerated 
tooth except the loss of the tooth. But when the tooth is not worth 
saving, or when there are signs of blood poisoning, as shown by 
chills and fever, or when there is danger of abscess in the face, 
as evidenced by much swelling, it is wiser to have the tooth ex- 
tracted to afford free drainage for the pus. There is no excuse for 
the dentist who refuses to extract an ulcerated tooth instantly, unless 
he can relieve the trouble by opening up the root of the tooth. It 
may be necessary to open the gum, as well as to extract the tooth, 
when there is much pus in the glim. 

If the patient is desirous of saving the tooth and there is no 
danger of blood poisoning or abscess in the face or neck, he may 



MOUTH BREATHING 437 

stay in bed with an ice bag on the face and take ten drops of 
laudanum * in water at intervals of three hours ; or better, he may 
be given a subcutaneous injection of morphin by a doctor. Then 
the gum should be lanced as soon as swelling there shows the pres- 
ence of pus. This latter advice applies to cases where the patient 
has not seen a dentist early enough to relieve the trouble by treating 

the tooth. 

TOOTHACHE FROM DECAY AND CAVITY 

When there is a cavity in an aching tooth it should be cleaned 
of food with a toothpick and, if it can be managed, it is also well 
to wipe the cavity dry with a wisp of absorbent cotton wound on 
the end of a moistened toothpick. 

The cavity may be most conveniently filled with one of the so- 
called toothache gums sold by all druggists. These contain some 
creosote and oil of cloves usually, and the gum may be inserted 
in the cavity with a toothpick and the fingers. Otherwise one may 
loosely pack the cavity with a small piece of absorbent cotton rolled 
between the fingers and saturated with creosote or oil of cloves, 
preferably the latter. If creosote is used one must be careful to 
squeeze any excess of the fluid out of the cotton before introducing 
it into the tooth or it will burn the mouth. (For care of the teeth, 
see Part II, Chapter II.) 

MOUTH BREATHING— INCLUDING ADENOIDS, CHRONIC TONSIL- 
LITIS, DEVIATION OF THE NASAL SEPTUM, ENLARGED TUR- 
BINATES, AND POLYPI 

Adenoids. — Any obstruction in the nose causes mouth breathing, 
and gives rise to one or more of a long train of unfortunate results. 
Among the disorders producing mouth breathing, enlargement of 
the glandular tissue in the back of the nose and throat of children 
is most important. Glandular growths in the upper part of the 
throat opposite the back of the nasal cavities are known as "adenoids" ; 
they often completely block the air passage at this point, so that 
breathing through the nose becomes difficult. 

Enlarged Tonsies. — Associated with this condition we usually 

1 Laudanum is a powerful drug (opium) and can only be bought on a doc- 
tor's prescription. 



438 THE XOSE, MOUTH, AXD THROAT 

see enlargement of the tonsils — two projecting bodies, one on either 
side of the entrance to the throat at the back of the mouth. In 
healthy throats the tonsils should not be visible. The tonsils are 
situated between two folds of membrane or pillars, as they are called, 
the more forward ones forming narrow curtains at either side of 
the back of the mouth, partitioning it to a slight extent from the 
throat behind. 

We are unable to see adenoids because of their position, but 
we can be reasonably sure of their presence in children when we 
find the signs and symptoms resulting from mouth breathing, as 
described below. When the tonsils are enlarged in children the ex- 
istence of adenoid growths also is practically certain. 

The surgeon assures himself positively of the existence of 
adenoids by inserting a forefinger into the mouth of the patient and 
hooking it up back of the roof of the mouth, when they may be felt 
as a soft mass filling the back of the nose passages. 

Other less common causes of mouth breathing, seen in adults 
as well as in children, are deviation of the nasal septum, swelling 
of the mucous membrane covering certain bones in the nose 
(turbinates), and polypi. 

Deviatiox of the Xasal Septum. — Deviation of the nasal sep- 
tum means displacement of the partition dividing the two nostrils, 
so that more or less obstruction exists. 

This condition may be occasioned by blows on the nose received 
in the accidents common to childhood. The deformity which results 
leads in time to further obstruction in the nose because, when air is 
drawn in through the narrowed passages, a certain degree of vacuum 
and suction on the walls of the nose is produced, as would occur if 
we drew in air from a large pair of bellows through a small, thin 
rubber tube. This induces an overfilling of the blood vessels in the 
walls of the passages of the nose, and the continued congestion is 
followed by increased thickness of the lining mucous membrane, thus 
still further obstructing the entrance of air. A one-sided nasal 
obstruction in a child, with discharge from that side, leads one to 
suspect that a foreign body has been put in by the child — such as a 
shoe button. 



MOUTH BREATHING 439 

Polypi. — Polypi are small pear-shaped growths which form on 
the membrane lining the nasal passages, and sometimes completely 
block them. They are soft, red and pulpy, and are apt to bleed 
easily. 

Causes. — These, then, are the usual causes of mouth breathing, 
but of most importance on account of their frequency and bearing 
on health and development are adenoids and enlarged tonsils in 
children. Adenoids and enlarged tonsils are often due to inflam- 
mation of these glands during the course of the contagious eruptive 
diseases, as scarlet fever and measles; diphtheria also is a cause. 
Probably, constant exposure to a germ-laden atmosphere is con- 
ducive to enlarged tonsils and adenoids, as they are pretty constant 
in children herded in tenements. 

Symptoms. — The mouth breathing is more noticeable during 
sleep ; snoring is common, and the breathing is of a snorting character 
with prolonged pauses. Children suffering from enlarged tonsils 
and adenoids are often backward in their studies, look dull, stupid, 
and even idiotic, are often cross and sullen ; the mouth remains open, 
and the lower lip is rolled down and is prominent; the nose has a 
pinched aspect, and the roof of the mouth is high. Air drawn 
into the lungs should be first warmed and moistened by passing 
through the nose, but when inspired through the mouth, produces 
so much irritation of the throat and air passages that constant 
colds, chronic catarrh of the throat, laryngitis, and bronchitis may 
ensue. 

Then the continued irritation of the throat occurring in mouth 
breathers weakens the natural resistance against such diseases as 
acute tonsillitis, scarlet fever, and diphtheria, so that they are espe- 
cially subject to these diseases. But these are not the only ailments 
to which the mouth breather is liable, for earache and deafness 
naturally follow the catarrh, owing to the obstruction of the 
eustachian tubes (see Earache and Deafness, Part III, Chapter 
XII). 

Deformity of the chest is another result of obstruction to nose 
breathing, the common form being the "pigeon breast," where the 
breast bone is unduly prominent. The voice is altered so that the 



440 THE NOSE, MOUTH, AND THEOAT 

patient "talks through his nose," although in reality nasal resonance 
is reduced and difficulty is experienced in pronouncing the letters 
n and m correctly, while stuttering is not an uncommon occur- 
rence. 

Nasal obstruction leads to poor general nutrition ; hence children 
with enlarged tonsils and adenoids are often puny and weakly 
specimens. 

While adenoid growths are most common in children, they are not 
at all rare in adults. The chronically enlarged tonsil is always a 
diseased tonsil and seriously threatens the general health. Persons 
with enlarged tonsils are subject to frequent sore throats in the 
winter months and acute tonsillitis. Enlarged tonsils are the most 
common cause of swollen glands in the neck in children. 

The enlarged tonsil harbors germs, and these produce poisons, 
and both may continually leak into the blood, setting up infections 
in distant organs. Thus it has become well recognized that enlarged 
tonsils are the most common cause of chronic rheumatism and fre- 
quently lead to heart and kidney disease and pleurisy, and, not 
improbably, to gall-bladder troubles and appendicitis. The tonsil 
which is enlarged should be cut out at the earliest opportunity in 
adult or child. 

Treatment. — The treatment is purely surgical in all cases of 
nasal obstruction. Removal of the adenoid growths, enlarged tonsils 
and polypi, straightening the displaced septum or removing the 
hard portion and leaving simply the membranous partition, and 
cauterizing the thickened mucous membrane obstructing the nasal 
passages, comprise the various common procedures. Xone of the 
operations is dangerous if properly performed and they should be 
generally done, even in the case of delicate children, as removal of 
the cause is the means of overcoming this delicacy. 

The common operation in children is removal of enlarged tonsils 
and adenoid growths for which ether is generally given, or some- 
times only nitrous oxid gas. In operations on enlarged tonsils one 
cannot too strongly emphasize the fact that they should be completely 
removed and not merely amputated in part, as has been hitherto the 
accepted routine operation. In such cases the trouble may not be 



MOUTH BREATHING 441 

at all improved and may even be made worse. The operation has 
consequently fallen into disrepute because the tonsils are said to 
"grow again" — the real fact being that they were never wholly 
removed. 

A tonsil completely removed cannot grow again any more than 
a finger after its removal. In adults, removal of the tonsils is done 
under the use of local injection of cocain. There are but compara- 
tively few doctors who do the complete tonsil operation, even at the 
present time. 

The aftertreatment in children is not unimportant, consisting in 
the use of a simple, generous diet, as plenty of milk, eggs, bread 
and butter, green vegetables and fresh meat, and the avoidance of 
pastries, sweets, fried food, pork, salt fish and salt meats, and also 
the roots, as parsnips, beets and turnips ; and tea and coffee. 

Life in the open air, emulsion of cod liver oil, daily sponging 
with cold water while the patient stands in warm water, followed 
by vigorous rubbing, will all assist the return to health. 

ACUTE TONSILLITIS 

(Follicular Tonsillitis) 

Tonsillitis is a germ (chiefly streptococci) disease and is con- 
tagious. Exposure to cold and wet and to germ-laden air renders 
persons more liable to attacks. It is more likely to occur in young 
people, especially those who have already suffered from the disease 
and whose tonsils are chronically enlarged, and is most prevalent 
in this country in the spring. The disease is often associated with 
rheumatism. 

Recently it has been found that epidemics of tonsillitis are due 
to milk. The germs (streptococci) in the milk are either derived 
from an inflamed cow's udder or from contamination of milk by per- 
sons who have the germs in their throats. Thus in Boston in May, 
1911, within a few days, 1,048 cases arose from milk, with forty- 
eight deaths. Boiling or pasteurizing milk (at home) will prevent 
such outbreaks. 

Certain complications may follow tonsillitis, especially in the 
severe epidemics. These include swelling of the glands of the neck, 



442 THE NOSE. MOUTH, AM) THROAT 

joint inflammation, abscess in the ear, heart disease, pneumonia and 
peritonitis. 

Symptoms. — Tonsillitis begins much like grippe, with fever 
(102° to 105° F.), headache, backache and pain in the limbs, sore 
throat, and pain in swallowing. On inspecting the throat (with 
the tongue held down firmly by a spoon handle and the mouth widely 
open in a good light, preferably sunlight) the tonsils will be seen 
to be swollen, much reddened, and dotted over with pearl-white 
spots. 

Sometimes only one tonsil is so affected, but the other is likely 
to become inflamed also. Occasionally there may be only one white 
spot on the tonsil. The swelling differs in degree : in some cases. 
the tonsils may be so swollen as almost to meet, but there is no 
danger of suffocation from obstruction of the throat, as occurs in 
diphtheria and 'very rarely in quinsy. The characteristic appear- 
ance, then, consists in large, red tonsils covered with white spots. 
The spots represent discharge which fills in the depressions in the 
tonsil. The fever lasts three days to one week generally, and it then 
subsides together with the other symptoms. 

Diagnosis. — With apparent tonsillitis there must always be kept 
in mind the possibility of diphtheria, and. unfortunately, it is at 
times impossible for the most acute physician to distinguish between 
these two diseases by the appearance of the throat alone. 

In order to do so it is necessary to rub off some of the discharge 
from the tonsils, and examine, microscopically, the kind of germs 
contained thereon. The following are the general points of differ- 
ence: In diphtheria the tonsils are usually completely covered with 
a gray membrane. In the early stage, or in mild cases of diph- 
theria, there may be only a spot on one tonsil, but it is apt to be 
yellow in color, and is thicker than the white spots in tonsillitis. 
These are the difficult cases. Ordinarily, in diphtheria, not only 
are the tonsils covered with a grayish membrane, but this soon extends 
to the surrounding parts of the throat, whereas in tonsillitis the 
spots are always found on the tonsil alone. The white spot can 
be readily wiped off with a little absorbent cotton wound on a 
stick, in the case of tonsillitis, but in diphtheria the membrane can 



MOUTH BREATHING 443 

be removed in this way only with difficulty, and leaves underneath a 
rough bleeding surface. The breath is apt to have a bad odor in 
diphtheria, and the temperature is lower (not much over 102° F.) 
than in tonsillitis, when it is frequently 103° to 105° F. 

Notwithstanding these points, it is never safe for a layman to 
undertake the diagnosis when a physician's services are obtainable. 
On the other hand, when this is not possible and the patient's tonsils 
present the white, dotted appearance described, especially if the per- 
son has been subject to similar attacks, one may be reasonably sure 
that the case is one of tonsillitis. 

Treatment.— The patient should be put to bed and kept apart 
from children and young persons, and, if living among large numbers 
of people, should be strictly quarantined. For although tonsillitis 
is not dangerous, it quickly spreads in institutions, boarding schools, 
etc. If the tonsils are painted with a solution of silver nitrate 
(one drachm to the ounce of water), applied carefully with a camel's- 
hair brush, at the beginning of the attack, with two applications 
twelve hours apart, the disease may sometimes be arrested. It is 
well also at the start to open the bowels with calomel, giving three 
grains in a single dose, or divided doses of one-half grain each 
until three grains have been taken. The outside of the throat should 
be kept covered with a wet flannel wrung out in cold water and 
covered with oil silk, or an icebag for the neck may be conveniently 
used in its place. 

One-half teaspoonful of the following prescription is beneficial 
unless it disagrees with the stomach. It must not be taken within 
half an hour before eating, and is not to be diluted with water. It 
acts, partly through its local effect on the tonsils, when allowed to 
flow from a spoon on the back of the tongue. 

Tincture of chlorid of iron ^4 ounce 

Glycerin 4 ounces 

Mix.' Directions: One-half teaspoonful every half hour. 

A mixture of hydrogen dioxid — equal parts with water, can 
also be used to advantage as a spray in an atomizer every two hours. 



444 



THE NOSE, MOUTH, AND THROAT 




The iron preparation and spray should be continued until the 

throat regains its usual condition. 

A liquid diet is desirable during the first part of the attack, 

consisting of milk, cocoa, 
egg nog (made of the white 
of egg), soups, and gruels; 
a . orange juice may be al- 
lowed, also grapes. The 
bowels must be kept regular 
with mild remedies, as a 
Seidlitz powder in a glass 
of water in the morning, or 
a one or two grain tablet of 
extract of cascara sagrada 

Fig. 56. — Quinsy or Abscess of the Tonsil. The a * nignt. 

shownlu^ ^ abSCGSS Sh ° Uid be ° Pened iS In P er sons who have had 

tonsillitis the tonsils are 
usually chronically diseased and enlarged. The tonsils should be 
removed under these circumstances to prevent future attacks of ton- 
sillitis and the train of serious sequelae noted above under Symptoms 
of Mouth Breathing. 

QUINSY 

Quinsy is a peritonsillitis ; that is, it is an inflammatory disease 
of the tissues in which the tonsil is imbedded, an inflammation 
around the tonsil. The swelling of these tissues thrusts the tonsil 
out into the throat ; but the tonsil itself is little affected. Quinsy in- 
volves then the structures surrounding the tonsil, and usually results 
in abscess. 

The disease is said to be frequently hereditary, is more often 
seen in persons under thirty-five, and often occurs in those subject 
to rheumatism and gout. It is seen more often in spring and 
autumn and in those living an out-of-door existence. Having once 
had quinsy, the victim is liable to frequent recurrences of the 
disease. 

Causes. — The causes of quinsy are the same as for tonsillitis. 
Chronically enlarged and diseased tonsils are the most frequent 



QUINSY 445 

cause of quinsy, and their removal will prevent future attacks. 
To surely prevent quinsy they must, however, be wholly dissected 
out and not merely have their tops cut off, as was formerly done. 

Symptoms. — Quinsy is characterized by much greater pain in 
the throat and in swallowing than is the case in tonsillitis, and the 
temperature is often higher — sometimes 104° to 105° F. The 
disease comes on with headache, backache, and chilly feelings, and 
patients who have once had quinsy will usually be able to correctly 
foretell an attack before there is much swelling in the throat. This 
is the time to begin treatment. 

When the disease is advanced and the throat is inspected, one 
or both tonsils are seen to be enlarged and crowded into the entrance 
to the throat, from the swelling of the neighboring parts (Fig. 56). 
The tonsils may indeed almost block the entrance to the throat ; the 
voice is thick and indistinct; the glands in the side of the neck be- 
come swollen ; there is often earache ; and the neck is sore and stiff, 
while the mouth can be only partially opened on account of pain. 
For the same reason the patient can swallow neither solid nor liquid 
food, and sits bent forward, with saliva running out of the mouth. 
The secretion of saliva is increased, but is not swallowed on account 
of the pain produced by the act. Sleep is also impossible, and alto- 
gether a more piteous spectacle of pain and distress is rarely seen. 

Having reached this stage, the inflammation usually goes on 
to abscess (formation behind, or above or below the tonsil), and, 
after five to ten days from the beginning of the attack, the pus 
finds its way to the surface of the tonsil, and breaks into the mouth, 
to the inexpressible relief of the patient. This event is followed by 
quick subsidence of the symptoms. 

Quinsy is rarely a dangerous disease, yet occasionally it leads 
to so much obstruction in the throat that death from suffocation 
ensues unless a surgeon opens the throat and inserts a tube. Very 
rarely the pus from the ruptured abscess enters the larynx and 
causes suffocation. 

Quinsy differs from tonsillitis in the following respects: the 
swelling affects the immediate surrounding area of the throat ; there 
are no white spots to be seen on the tonsil unless the trouble begins 



446 THE NOSE, MOUTH, AND THEOAT 

as an ordinary tonsillitis; there is great pain on swallowing; and 
finally, abscess forms near the tonsil in most cases. 

Treatment. — A thorough painting of the tonsils at the onset of 
a threatened attack of quinsy with a twelve per cent, silver- nitrate 
solution, as recommended under tonsillitis, may cut short the dis- 
order. A single dose of calomel (three to five grains) is also useful 
for the same purpose. 

The constant use of a hot flaxseed poultice (as large as the whole 
hand and an inch thick, spread between thin layers of cotton, applied 
as hot as can be borne, and changed every half hour) gives the 
greatest relief, and may possibly lead to disappearance of the trouble, 
if employed early enough. The use of the poultices is to be kept 
up until recovery, although they need not be applied so frequently 
as at first. 

A surgeon's services are especially desirable in this disorder, as 
early puncture of the peritonsillar tissue may save days of suffering 
in affording exit for pus as soon as it forms. 

The tonsils should be removed after an attack of quinsy to pre- 
vent recurrence of the trouble and to avoid the dangers of chronic 
tonsillitis {See Symptoms of Mouth Breathing). 

DIPHTHERIA * 

Diphtheria is an acute infectious disease, characterized by a 
grayish membrane in the throat, produced by a special germ (Klebs- 
Loffler bacillus), and by fever and general symptoms caused by the 
poison formed in the growth of the germs. 

No layman should ever attempt to treat diphtheria. The con- 
sideration of the disease in this book is mainly of importance in 
emphasizing the necessity of calling in expert medical advice at the 
earliest moment in suspicious cases of throat trouble, for, as we 
noted under tonsillitis, it is impossible in some cases for the expert 
to decide from the appearance of the throat whether the disease is 
tonsillitis or diphtheria. 

A specimen of the secretion from the throat removed by the 
doctor for microscopical examination by a bacteriologist, to deter- 
mine the presence of diphtheria germs, will alone decide the point. 



DIPHTHERIA 447 

When such an examination is impossible, it is always best to isolate 
the patient, especially if a child, and treat the case as if it were 
diphtheria. 

Causes. — How is diphtheria acquired? Chiefly from contact 
with patients who have recovered sufficiently to go about but still 
carry the germs in their throats. This is prevented by Boards of 
Health requiring that patients shall be free from germs before they 
are released from quarantine. But diphtheria bacilli are found in 
the throats of one per cent, of healthy persons, and almost two per 
cent, of some 1,000 children in New York tenements were found 
to harbor virulent diphtheria germs in their throats. 

Some persons are not susceptible to the diphtheria germs in 
their throats, and yet these same germs may be transmitted to others 
who will develop the disease. The germs will live for months on 
various articles, especially damp cloth. Various objects interchanged 
in school, as pencils, candy, gum and towels, may convey the germ. 
Many recent epidemics have originated in milk which has become con- 
taminated in its route from the cow to the consumer by the hands or 
mouth of some person. 

The subjects of mild and unrecognized cases, the healthy 
"carriers" of the germs, and convalescents from diphtheria, who 
may have the germs in their throats for many months after recovery 
from the disease, are the chief sources of the contagium. Emana- 
tions from sewage, formerly thought a cause of the disease, are now 
known not to be so. 

Period of Development. —After exposure to diphtheria, from 
two to seven days elapse before the disease begins — more often two 
days (Osier). 

Symptoms. -Diphtheria commences with fever (102° to 103° E.)-, 
chilliness or severe chills, pain in the back and limbs, and often 
sore throat, and pain in swallowing. It may not be until the third 
day that the dirty gray or yellowish membrane forms on the tonsils 
and creeps up on the surrounding parts, as the palate (the soft 
curtain forming the roof of the back of the mouth), and the uvula 
(the little body hanging from the palate in the back of the mouth), 
and the bands (pillars) in front of the tonsils. But it may be. that 



448 THE NOSE, MOUTH, AND THROAT 

a case with only a single white spot on the tonsil is diphtheria ; 
that a case with a red, sore throat, without any white spot at all, is 
diphtheria ; and that a case with the tonsils dotted over with white 
spots, as seen in tonsillitis, is diphtheria. Of course, these instances 
are not common, but every doctor has seen them. 

So that it is safer that a doctor take a specimen of the secretion 
from any sore throat, for laboratory examination, before committing 
himself to diagnosis. Persons are often more sick in the beginning 
with tonsillitis, than they are with diphtheria, for the fever is 
usually lower in diphtheria, and the headache, backache, and pains 
in the limbs less severe. Diphtheria is most common in children 
under five years (80 per cent, of cases) because they creep about 
the floor and place all sorts of articles in their mouths. In addition 
to the symptoms noted there is swelling of the glands of the neck, 
appearing as lumps under the back of the jaw, and pallor and 
weakness are marked. 

Diphtheria may occur in many parts of the body other than in 
the throat. The next most frequent form is that in the nose. Nasal 
diphtheria may begin in the throat and extend to the nose, in severe 
cases, or the nose may alone be attacked, the throat showing no 
membrane. There is a watery or bloody discharge from the nostrils 
making the skin raw, and lumps or enlarged glands appear under 
the jaw, while fever and general symptoms may be more severe 
than in the throat form. 

There is a mild form in which children feel well enough to 
play and go to school, and in which fever is absent, but in which 
discharge from the nose and membrane are present. 

Certain conditions in the throat and mouth favor the growth 
of diphtheria germs, as bad teeth, enlarged tonsils, catarrh of the 
nose and throat, and sore mouth. 

There are many complications of diphtheria. Heart failure is 
more common than in any other acute disease. Patients should 
always be kept in bed for some time after the membrane has dis- 
appeared for this reason. Heart trouble may not begin until the 
third to the sixth week of the disease after apparent recovery. There 
are vomiting, pain in the chest and region of the heart, difficult 



DIPHTHERIA 449 

breathing, and blueness of the lips and nails. Inflammation of the 
kidney (frequent examination of the urine is necessary) and paralysis 
are common complications. The paralysis is most often of the 
palate and there is difficulty in swallowing, so that liquids are re- 
turned from the nose, and the voice is nasal. This may appear in 
the second or third week and lasts about the same length of time. 
The legs are sometimes paralyzed, but recovery after months is the 
rule. Abscess in the ears and of the glands of the neck are occasional 
complications. 

Membrane in the throat and nose does not always mean diph- 
theria, but usually this is the case. Occasionally (in about 25 per 
cent, of cases) other germs in scarlet fever, measles, whooping- 
cough, etc., give rise to a similar condition which can only be dis- 
tinguished from true diphtheria by isolation of the germs from the 
throat in the laboratory. Moderate cases of diphtheria are of one 
to two weeks' duration. 

One point which cannot be too strongly emphasized is that the 
throat of every sick child should be examined, as sore throat is often 
not complained of. 

It is not uncommon for patients with mild forms of diphtheria to 
walk about and attend to their duties, and, in the case of children, 
to go to school and spread the disease in that inviting field. They 
may present only a red throat, or perhaps a white spot on one tonsil. 
In the case of sore throat in persons who have been exposed to diph- 
theria, especially if children, a specimen of mucus from the throat 
should always be sent to a pathological laboratory for microscopical 
examination. 

Those persons with apparently normal throats who carry about 
diphtheria germs can only be discovered by laboratory examination 
of the secretion of their throats. 

Outlook. —The use of antitoxin has wholly altered the death rate 
in diphtheria. The general death rate in some 183,000 cases of 
diphtheria in 150 cities, without antitoxin, was 38.4 per cent., and 
in 132,000 cases, with antitoxin, was 9.8 per cent. (Osier). The 
disease is naturally more fatal without antitoxin in infancy and 
lessens in fatality with age. Thus 87 per cent, of children die 



450 THE NOSE, MOUTH, AXD THEOAT 

during the first year; there is 20 to 25 per cent, mortality at the 
tenth year: and only one or two per cent, after the fortieth year. 
Notwithstanding this, old persons die of diphtheria, as George 
Washington, whose death in his sixty-eighth year was due to this 
disease. In cases in which antitoxin is given on the first appearance 
of the membrane the mortality is almost nil. 

It is unwise for a physician in doubt as to the diagnosis to 
wait for a laboratory examination in a suspicious case. It takes 
at least twelve hours to get a report, and two or three examinations 
are sometimes necessary to secure a reliable diagnosis. It is not 
uncommon for the first report to be ' 'negative*' while the second 
report is "positive." Many lives have been lost through waiting 
for the result of laboratory examinations, since the favorable effects 
of antitoxin depend upon its early use. TThen the throat looks 
suspicious let the doctor give antitoxin at the same time that he takes 
the specimen for the laboratory. If the case turns out not to be 
diphtheria no harm is done, but if the disease is present, a life may 
have been saved. 

Prevention. — The injection of small doses of antitoxin into per- 
sons who have been exposed to diphtheria will certainly prevent the 
disease. The immunity lasts about three weeks. Antitoxin was 
at first thought to be free from danger, but it has been found that 
death rarely results from its use in prevention or treatment of 
disease. The number of deaths compared to the frequency of its 
use is exceedingly small — one death in IS. 000 injections according 
to some statistics. There is almost no danger in giving it to infants, 
as antitoxin has been injected into every child as a routine pro- 
cedure each month in the Boston Children's Hospital, for a long 
period, without a death. Persons who have already had antitoxin, 
those who are subject to asthma, and those who are affected by the 
smell or proximity of horses, are more likely to suffer. If anti- 
toxin is repeated every day or two there is no danger, but if a week 
or more has elapsed, or even years, after the last dose there may be 
danger from its repetition. 

In such cases only two drops of antitoxin should be injected, 
which is perfectly safe for anyone, and if no unpleasant symptoms 



DIPHTHERIA 451 

have occurred after three hours, an ordinary dose may be given. 
It would be safer to use this method in any case where antitoxin 
is used for prevention or for treatment in persons possibly suscep- 
tible (see above). In the event of patients who present dangerous 
symptoms after injection of antitoxin — as distress, difficult breath- 
ing, blueness of the lips and finger nails, with failure of the pulse 
and breathing — the injection of one-fourth grain of morphin and 
one-hundredth grain of atropin is the proper treatment. 

It is not infrequent for a rash like hives to appear in a week 
or ten days after the injection of antitoxin, and rarely there are 
some fever and pains in the limbs with swelling of the glands. The 
symptoms are usually mild, however, and last but a few days. 

A new skin test (Schick) may be used to determine the suscep- 
tibility of a person to diphtheria — especially immediately after ex- 
posure. Most infants are born with immunity to the disease, in- 
herited from their mother's blood. This passes off in a few years, 
and they become susceptible, but a large percentage of adults are im- 
mune, owing to a previous attack of the disease, or from the pres- 
ence of diphtheria germs in their throats without the occurrence of 
diphtheria. When danger is not imminent a vaccine may be used to 
prevent diphtheria. 

Treatment. —The treatment of diphtheria consists, first, in the 
use of antitoxin, and in rest in bed, with a rich, liquid diet. The 
antitoxin is injected under the skin, and large doses are much safer 
than small ones. The average first dose should be five thousand 
units. This may be repeated every six hours until improvement 
sets in in severe cases. Of course, such treatment can only be properly 
carried out by a physician, and the earlier the better. 

Syringing the nose with boric acid solution (as much as will 
dissolve in warm water) from a fountain syringe, held but two feet 
above the patient, is desirable in children with nasal diphtheria. The 
tube should be introduced horizontally into one nostril, so that the 
solution will flow out the other. The throat should also be swabbed 
twice daily with hydrogen peroxid (1 part) and water (3 parts). 

Young children make such a fuss over local treatment that it 
is often as well to rely wholly upon antitoxin. In persons who 



452 THE NOSE, MOUTH, AND THEOAT 

have previously had antitoxin, in those susceptible to asthma or the 
presence of horses, the trial dose of two drops should be used before 
giving the usual amount. 

MEMBRANOUS CROUP 

Membranous croup is usually (in 80 per cent, of cases) diph- 
theria of the inside of the lower part of the throat (larynx), in the 
region of the Adam's apple. The chief object should be to distinguish 
membranous croup from ordinary catarrhal croup, in which there is 
spasm and swelling of the inside of the throat, but no membrane 
to obstruct it. 

Usually the child with ordinary croup goes ' to bed well, or 
perhaps with a slight cold, and awakens in the night with the hard, 
barking cough, and crowing or whistling breathing of croup. This 
is soon relieved by application of cold cloths to the outside of the 
throat, by inhaling steam in the air of the room, and by taking- 
half a teaspoonful of syrup of ipecac. Similar attacks may return 
on the next night or two, the child remaining comfortable during 
the day, except for an occasional hoarse cough. 

Membranous croup begins in the same way as ordinary croup, 
for the first day or two, but then begins to grow suddenly worse 
with difficult breathing, hoarse or whispering voice, great restless- 
ness, blueness of the lips and nails, and finally stupor. Fever is 
moderate, as in ordinary croup, but there is usually swelling of the 
glands behind the jaw. Persistent croup of increasing severity 
usually means membranous croup or diphtheria in the lower part of 
the throat. In at least fifty per cent, of cases membranous or white 
spots may- be seen on the tonsils or upper part of the throat, and in 
many cases when this is not apparent, it is coughed up. 

In membranous croup, when breathing is much obstructed, it 
will be necessary for a doctor to introduce a tube into the throat to 
be worn for some time. The tube inserted through the mouth 
(intubation tube) is generally preferable in children, although that 
one which is introduced through a wound in the outside of the throat 
(tracheotomy tube) may be preferable in children and usually is 
in adults. 



HOARSENESS 453 

HOARSENESS 

(Acute Laryngitis) 

This is an acute inflammation of the mucous membrane of the 
larynx. The larynx is that part of the throat, in the region of the 
Adam's apple, which incloses the vocal cords and other structures 
used in speaking. 

Hoarseness is commonly due to extension of catarrh from the 
nose in cold in the head and grippe. It also follows overuse of the 
voice in public speakers and singers, and is seen after exposure to 
dust, tobacco or other smoke, and very commonly in those addicted 
to alcohol. 

Symptoms. — Hoarseness is the first symptom noticed, and per- 
haps slight chilliness, together with a prickling or tickling sensation 
in the throat. There is a hacking cough and expectoration of a 
small amount of thick secretion. There may be slight difficulty in 
breathing and some pain in swallowing. 

The patient feels generally pretty well and is troubled chiefly 
by impairment of the voice, which is either husky, reduced to a 
mere whisper, or entirely lost. This condition lasts for some days 
or, rarely, even weeks. There may be a mild degree of fever at the 
outset (100° to 101° P.). Very uncommonly the breathing becomes 
hurried and embarrassed, and swallowing painful, owing to exces- 
sive swelling and inflammation of the throat, so much so that a 
surgeon's services become imperative to intube the throat or to 
open the windpipe, in order to avoid suffocation. This serious 
form of laryngitis may follow colds, but more often is brought about 
by swallowing very hot or irritating liquids, or through exposure to 
fire or steam. 

In children, after slight hoarseness for a day or two, if the 
breathing becomes difficult and is accompanied by a crowing or 
whistling sound, with blueness of the lips and signs of impending 
suffocation, the condition is very suggestive of membranous croup 
(a form of diphtheria), which certainly is the case if any white, 
membranous deposit can be either seen in the throat or is coughed 
up. Whenever there is difficulty of breathing and continuous hoarse- 



454 THE NOSE, MOUTH, AND THROAT 

ness, in children or adults, the services of a competent physician are 
urgently demanded. 

Treatment. —The patient should take a bottle of effervescing 
magnesium citrate or other saline at the onset of the attack. The 
use of cold is advantageous. Cracked ice may be held in the mouth, 
ice cream can be employed as part of the diet, and an icebag may be 
applied to the outside of the throat. The application of a linen 
or flannel cloth to the throat wrung out of cold water and covered 
with oil silk or waterproof material, is also beneficial, and often 
more convenient than an icebag. Heat is as useful in laryngitis 
as cold, for persons who find it more agreeable. Flannel may be 
wrung out in hot water and applied to the throat and covered with 
oil silk and dry bandage. Frequent renewal of the application is 
necessary. 

The patient must absolutely stop talking and smoking. If the 
attack is at all severe, he should remain in bed. If not so, he must 
stay indoors. At the beginning of the disorder a teaspoonful of 
paregoric 1 and twenty grains of sodium bromid are to be taken in 
water every three hours, by an adult, until three doses are swal- 
lowed. 

Inhalation of steam from a pitcher containing boiling water is 
to be recommended. A tablespoonful of compound tincture of benzoin 
poured on the surface of the boiling water increases the efficacy of 
the steam inhalation. The head should be held above the pitcher, 
and a towel should cover both the head and pitcher to retain the 
vapor. 

The employment, every two hours, of a spray from an atomizer, 
consisting of adrenalin chlorid solution (1 part in 10,000 of water) 
is most useful. This should be inhaled for some time into the 
lungs. Then this is immediately followed by another spray con- 
taining menthol and camphor (of each, ten grains) dissolved in 
albolene (two ounces), which should be continued throughout the 
disease. If the hoarseness persists and tends to become chronic, 
it is most advisable for the patient to consult a specialist in throat 
diseases for local examination and special treatment. 

1 Paregoric (opium) may be obtained only on a doctor's prescription. 



CROUP 455 



CROUP 



Croup is an acute laryngitis of childhood, usually occurring 
between the ages of two and six years. The nervous (spasmodic) 
element is more marked than in adults, so that the symptoms appear 
more alarming. 

Symptoms. — The trouble frequently arises as part of a cold, or 
as a forerunner of a cold, and often is heralded by some hoarse- 
ness during the day, increasing toward night. The child may then 
be slightly feverish (temperature not over 102° F., usually). He 
goes to bed and to sleep, but awakens, generally between nine and 
twelve p. m., with a hard, harsh, brassy, barking cough (croupy 
cough), and difficulty in breathing. The breathing is noisy, and 
when the air is drawn into the chest there is often a crowing or 
whistling sound produced from obstruction in the throat, due to 
spasm of the muscles and to dried mucus coating the lining mem- 
brane, or to swelling in the larynx. It is impossible to separate 
these causes. The child, as well as his parents, becomes frightened, 
and he cries and struggles, in this way aggravating the trouble. The 
worst of the attack is, commonly, soon over, so that as a rule the 
doctor arrives after it is past. While it lasts, however, the household 
is more apt to be alarmed than, perhaps, by any other common ail- 
ment. 

Death from an attack of croup, pure and simple, has probably 
never occurred. The condition described may continue in a less 
urgent form for two or three hours, and may reappear on following 
nights or days in a less severe form. The child falls asleep and 
awakens next morning with evidences of a cold, hoarseness, and 
cough, which may last several days or a week or two. 

The only other disease with which croup is likely to be confused 
is membranous croup (diphtheria of the larynx), and in the latter 
disorder the trouble comes on slowly, with hoarseness for two or 
three days and gradually increasing fever (103° to 105° F.), great 
restlessness, and difficulty in- breathing, not shortly relieved by treat- 
ment, as in simple croup. In fifty per cent, of the cases of mem- 
branous croup it is possible to see — with a good light — a white, 



456 THE NOSE, MOUTH. AXD THROAT 

membranous deposit on the upper part of the throat by holding the 
tongue down with a spoon handle and inspecting the parts. 

Croup is more likely to occur in children suffering from adenoids, 
enlarged tonsils, indigestion, and decayed teeth, and is favored by 
dry. furnace heat, by exposure to cold, and by screaming and shout- 
ing out of doors. 

Treatment. —Place the child in a warm bath (105' F.) and 
hold a sponge soaked in hot water over the Adam's apple of the 
throat, changing it as frequently as it cools. Hot camphorated oil 
rubbed over the neck and chest aids recovery. If the bowels are 
not loose, a teaspoonful of castor oil should be given or one or two 
grains of calomel. The most successful remedies are ipecac and 
paregoric. It is wise to keep both on hand with children in the 
house. A single dose of paregoric x (fifteen drops for child of two 
years; one teaspoonful for child of seven years) and repeated doses 
of syrup of ipecac (one-quarter to one-half teaspoonful) should be 
given every hour, until the child vomits and the cough loosens, and 
every two hours afterwards. 

Generation of steam near the child also is exceedingly helpful in 
relieving the symptoms. A kettle of water may be heated over a 
lamp. A rubber or tin tube may be attached to the spout of the 
kettle and carried under a sort of sheet tent, covering the child 
in bed. The tent must be arranged so as to allow the entrance of 
plenty of fresh air. 

Very rarely the character of the inflammation in croup changes, 
and the difficulty in breathing, caused by swelling within the throat, 
increases so that it is necessary to employ a surgeon to pass a tube 
down the throat into the larynx, or to open the child's windpipe 
and introduce a tube through the neck to prevent suffocation. 

The patient recovering from croup should generally be kept in a 
warm, well-ventilated room for a number of days after the attack 
and receive syrup of ipecac (ten drops) three or four times daily 
until the cough is loosened. If ipecac causes nausea or vomiting, 
the dose may be reduced. 

The disease may be prevented by a simple diet, especially at 

* Paregoric (opium) cannot be obtained without a doctor's prescription. 



CROUP 457 

night ; by the removal of enlarged tonsils and adenoids ; by daily 
sponging, before breakfast, with water as cold as it comes from 
the faucet, while the child stands, ankle deep, in hot water; and 
by an out-of-door existence, with moderate school hours ; also by 
evaporating water in the room during the winter when furnace heat 
is used. When children show signs of an approaching attack of 
croup, three doses of sodium bromid (five grains for a child two 
years old ; ten grains for one eight years old) should be given 
during the day at two-hour intervals. A warm bath before bedtime, 
and rubbing the chest and neck with hot camphorated oil, are also ad- 
vis 



CHAPTEE XI 
DISEASES OF THE AIE PASSAGES 

Cough. Bronchitis. Pneumonia. Consumption. Asthma. Hay-fever. 
Influenza or la grippe. 

COUGH OCCURRING IN BRONCHITIS, PNEUMONIA. CON- 
SUMPTION, OR TUBERCULOSIS, ASTHMA, AND INFLU- 
ENZA OR GRIPPE 

Cough is a symptom of many disorders. It may be caused by 
irritation of any part of the breathing apparatus, as the nose, throat, 
windpipe, bronchial tubes, and (in pleurisy and pneumonia) the 
covering membrane of the lung. The irritation which produces 
cough is commonly due either to congestion of the mucous membrane 
lining the air passages (in early stages of inflammation of these 
tissues), or to secretion of mucus or pus blocking them, and this 
occurs in the later stages. 

Cough is caused by a sudden, violent expulsion of air from the 
chest following the drawing in of a deep breath. A loose cough is 
to be encouraged, as by its means mucus and other discharge are 
expelled from the air passages. 

A dry cough is seen in the early stages of various respiratory 
diseases, as bronchitis, penumonia, pleurisy, consumption, whooping- 
cough, and with irritation from enlarged tonsils and adenoids, 
occurring in children. 

Irritation, produced by inhaling dust, or any irritation existing 
in the nose, ear, or throat, may lead to this variety of cough. The 
dry cough accomplishes no good, and if continuous and excessive 
may do harm. It demands medicinal relief. 

45S 



COUGH 459 

BRONCHITIS 

Cough following or accompanying cold in the head and sore 
throat generally indicates bronchitis. 

The larynx, or lower part of the throat, ends just below the 
"Adam's apple" in the windpipe. The windpipe is about four and 
one-half inches long and three-quarters to an inch in diameter, and 
terminates by dividing into the two bronchial tubes in the upper 
part of the chest. Each bronchial tube divides and subdivides in 
turn like the branches of a tree, the branches growing more numerous 
and smaller and smaller until they finally end in the microscopic air 
sacs or air cells of the lungs. The bronchial tubes convey air to 
the air cells, and in the latter the oxygen is absorbed into the blood, 
and carbonic acid is given off. 

Bronchitis is an inflammation of the mucous membrane lining 
these tubes. In the cough of an ordinary cold only the mucous 
membrane of the windpipe and, perhaps, of the larger tubes, is 
inflamed. This is a very mild disorder compared to inflammation 
of the smaller and more numerous tubes. 

Symptoms. — In bronchitis, besides the ordinary symptoms of a 
severe cold in the head, as sneezing, running of mucus from the 
nose, sore throat, some hoarseness (perhaps), and languor and sore- 
ness in the muscles, there is at first a feeling of tightness, pressure, 
and rawness in the region of the breastbone, with a harsh, dry 
cough. The coughing causes a strain of the diaphragm (the muscle 
which forms the floor of the chest), so that there are often pain and 
soreness along the lower borders of the chest where the diaphragm 
is attached to the inside of the ribs. After a few days the cough 
becomes looser, greatly to the patient's comfort, and a mixture of 
mucus and pus is expectorated. 

In a healthy adult such a cough is usually not in itself a serious 
affair, and apart from the discomfort of the first day or two, there 
is not sufficient disturbance of the general health to interfere with 
the ordinary pursuits. The temperature is the best guide in such 
cases; if it is above normal (over 99.5° F.) the patient should 
stay indoors. In infants, young children, enfeebled or elderly people, 



460 DISEASES OF THE AIR PASSAGES 

bronchitis may be a serious matter, and may be followed by pneu- 
monia through extension of the inflammation from the small bronchial 
tubes into the air sacs of the lungs, and infection with the pneumonia 
germ. 

The principal signs of severe attacks of bronchitis are cough, 
rapid breathing and pulse, and fever. 

The normal rate of breathing in adults is seventeen a minute, 
that is, seventeen inbreaths and seventeen outbreaths. In children 
of one to five years the normal rate is about twenty-six breathing 
movements a minute. In serious cases of bronchitis the rate may 
be twenty-five to forty in adults, or forty to sixty in children, 
per minute. 

Of course, the only exact way of learning the nature of a chest 
trouble is through careful examination by a physician, for cough, 
fever, rapid breathing, and rapid pulse occur in many other diseases 
besides bronchitis — particularly pneumonia. 

Treatment of Acute Cough and Bronchitis.— In the case of 
healthy adults with a cough accompanying an ordinary cold, the 
treatment is very simple, when there is little fever or disturbance 
of the general health. The remedies recommended for cold in the head 
(in the preceding chapter) should be taken at first. It is also particu- 
larly desirable for the patient to stay in the house, or better, in bed for 
the first day or two or until 'the temperature is normal. 

The feeling of tightness and distress in the chest may be relieved 
by applying a mild mustard paper over the breastbone, or a poultice 
containing mustard (one part) and flour (three parts) and warm 
water mixed into a paste and spread between two single thicknesses 
of cotton cloth about eight inches square. Tincture of iodin painted 
twice over a similar area forms another convenient application 
instead of the mustard. 

Children suffering from recent cough with fever should be kept 
in bed while their temperature is above normal. It is well to give 
infants at the start a grain of calomel or a teaspoonful of castor oil, 
and double the dose for children of five to eight years. 

The chest should be rubbed with a liniment composed of one 
part of turpentine and two parts of camphorated oil in mild 



COUGH 461 

while in more severe attacks the use of mustard (see below) is much 
more efficient. No more clothing than usual should be worn over 
the chest. The jacket of thick cotton wadding, formerly used, is 
now considered inadvisable. It is essential to keep the room at a 
temperature of about 68° F. and well ventilated, not permitting 
babies to crawl on the floor when able to be up, or to pass from a 
warm to a cold room. 

In the beginning of the attack syrup of ipecac every two hours 
is the best drug — two to three drops for a child under one year 
and up to three years, and later, five drops; children over ten and 
adults ten drops, unless it causes nausea or vomiting, when the dose 
may be reduced one-half. 

If children become " stuffed up" with secretion so that the breath- 
ing is difficult and noisy, a teaspoonful of the syrup of ipecac should 
be given to make them vomit, for until they are six or seven years 
old children cannot expectorate, and mucus which is coughed up into 
the mouth is swallowed by them. Vomiting not only gets rid of 
that secretion which has been swallowed, but expels it from the 
bronchial tubes. This treatment may be repeated if the condition 
recurs. 

In young children, medicine is to be avoided as far as possible. 
If coughing is so constant at night as to interfere with the sleep, 
paregoric x may be given in one-quarter of a glass of water as follows : 

Five drops at six months 

Ten drops at one year 

Twenty drops at three years 

Thirty drops at five years 

A teaspoonful at twelve years or over 

These drops should preferably be measured in a measuring glass. 
They may be repeated in two hours if necessary. 

A paste consisting of mustard (one part) and flour (eight parts) 
is very useful when spread in a layer one-fourth of an inch thick 
between two pieces of thin muslin, large enough to make two plasters, 
one covering the back and the other the whole front of the chest. 

1 Paregoric (opium) can now only be obtained by a doctor 's prescription. 



462 DISEASES OF THE AIK PASSAGES 

The skin under the plaster should be inspected from time to time, 
and when it is quite red the plaster should be removed and vaselin 
applied. The application of the mustard plaster should be repeated 
once in six hours, unless the skin is too red. 

In young children with severe attacks of bronchitis, as shown 
by rapid breathing, cold feet and hands, and much depression of 
spirits, the mustard bath is invaluable and may prevent an attack 
of pneumonia. One-half an ounce of Coleman's mustard (heaping 
tablespoonful) is mixed in twenty-four quarts of water at 110° P. 
(about as hot as can be comfortably borne) and the child is sub- 
merged in it for five or ten minutes. It may be repeated every 
six hours. 

The diet should be only milk for young children during the 
first day or two, and older patients should not have much more 
than this, except toast and soups. In feeble babies with bronchitis, 
it is wise to give five or ten drops of brandy or whisky in water 
every two hours, to relieve difficulty in breathing. 

Children who are subject to frequent colds, or those in whom 
cough is persistent, should receive cod-liver oil — one-half to one 
teaspoonful, according to age — three times daily after eating. One 
of the emulsions may be used instead, if the pure oil is unpalatable. 

Adenoids and enlarged tonsils are fruitful sources of constant 
colds and sore throat, and their removal is advisable. Children 
should be hardened by a cold sponge and brisk dry rub after the 
daily morning warm bath. Sleeping in rooms with the windows 
wide open, or better, out-of-doors, has also a good effect in preventing 
colds. Keeping young children bare-legged is an abomination and 
favors colds. Also children should wear long underdrawers in colder 
climates to cover the space between the tops of their stockings and 
drawers. When children have constant colds it will be found that 
an outdoor life in the country is usually the best cure. 

PNEUMONIA 

Symptoms. — Pneumonia begins suddenly, often with a severe 
chill, headache, and general pains like grippe. In a few hours 
cough commences, short and dry, with violent, stabbing pain in one 



COUGH 463 

side of the chest, generally near the nipple. The breathing becomes 
rapid, with expanding nostrils, the face is anxious and often flushed 
on one cheek. The matter coughed up at first is often streaked with 
blood, and is thick and jellylike. The temperature is frequently 
104° to 105° F. 

If the disease proceeds favorably, at the end of five, seven, or 
ten days, the temperature, breathing, and pulse suddenly become 
normal, and the patient rapidly emerges from a state of danger 
and distress to one of comfort and safety. The sudden onset of 
pneumonia with chill, agonizing pain in side, rapid breathing, and 
often delirium with later bloody or rusty-colored, gelatinous expec- 
toration, mil then usually, though not always, serve to distinguish 
it from bronchitis. 

Whenever, with cough, rapid and difficult breathing occurs with 
rise of temperature (as shown by the thermometer) and rapid pulse, 
the case .is serious, and medical advice is urgently demanded. 

Treatment.— Patients developing the symptoms desciibed as 
suggestive of pneumonia need the immediate attention of a physician. 
If a person is unfortunate enough to have the care of such a case, 
when it is impossible to secure a physician, it may afford some 
comfort to know that good nursing is really the prime requisite in 
aiding recovery, while skillful treatment is of most value if com- 
plications arise. 

The greatest recent advance in the treatment of pneumonia has 
been that of keeping the patient out-of-doors in a sheltered porch or 
piazza, or turning the room into outdoors in so far as possible by 
removing the window sash or using a window tent. There should 
be at least two windows on opposite sides of the room and the patient 
should be screened from direct drafts. Winter weather is as suitable 
as summer unless the temperature is below zero. 

The patient should be warmly, but not heavily, covered and a 
folded blanket and rubber sheet should be laid under the mattress 
to prevent the cold passing through it. The patient should have a 
hot water bag at his feet in cold weather. The bed should be moved 
indoors or into a warm room when the patient has to be bathed. 
A flannel jacket may be made, to surround the chest, and should 



■164 DISEASES OF THE AIE PASSAGES 

open down the whole front. The nightshirt is to be worn over 
this — nothing more. 

Daily sponging of the patient with tepid water (85° to 90° F.) 
should be practiced. The body is not to be all exposed at once, but 
each limb and the trunk are to be separately sponged and dried. If 
the fever is high (over 104° F.) the water should be cool (80° F.), 
and the sponging done every three hours in the case of a strong 
patient. The sponging is done for five minutes at a time, while 
the skin is being briskly rubbed to keep up the circulation. 

Visitors must be absolutely forbidden : no more than one or two 
persons are to be allowed in the sickroom at one time. 

The diet should consist chiefly of milk — a glass every two hours, 
varied with milk mixed with thin cooked cereal, or eggnog, or coffee, 
or tea (two cups daily), and broths, with orange juice once daily. 
It is wise to give a cathartic, such as five grains of calomel, followed 
in twelve hours by a Seidlitz powder, at the beginning of the disease, 
if the bowels do not act freely before that time. 

To relieve the pain in the side, if excruciating, one-quarter grain 
morphin sulphate * should be given, and repeated once in two hours, 
if necessary. The application of an icebag to the painful side 
frequently stops the pain (in children a hot flaxseed poultice is 
better) and, moreover, is excellent treatment throughout the course 
of the disease. The seat of pain usually indicates that the lung on 
that side is the inflamed one, so that the icebag should be allowed to 
rest against that portion of the chest. Water should be very freely 
supplied and should be given as well as milk, even if the patient is 
delirious. 

The bowels are to be moved daily by glycerin suppositories or 
injection of warm water. 

Death Rate. — The death rate in pneumonia differs greatly with 
circumstances. In hospital practice it varies from thirty to forty 
per cent., in private practice from six to seventeen per cent. Half 
the patients over sixty years of age die of pneumonia : eighty-seven 
per cent, die between seventy and eighty years. About one-third of 

1 Morphin is a powerful drug and can only be obtained by a doctor's 
prescription. 



COUGH 465 

infants under one year old die with pneumonia, while in the second 
year only one-sixth die. In some years the mortality from pneumonia 
is vastly greater than others, varying from five to thirty per cent. 

In specially selected young men, as soldiers, the death rate from 
pneumonia is only one in twenty-five cases. On the other hand, 
pneumonia is the common cause of death in old age. Persons enfee- 
bled with disease or suffering from excesses, particularly alcoholism, 
are also likely to die if stricken with the disease. 

Pneumonia is the cause of one in every ten deaths in the United 
States. 

CONSUMPTION 

(Tuberculosis of the Lungs — Phthisis) 

This disease is of extreme importance because, above all others, 
it is the great destroyer of human life, until recently causing one- 
seventh 1 of all deaths. But, on the other hand, so far from being 
such a fatal disease it may become an eminently curable one — if 
recognized in its earliest stage. The fact that practically everybody 
is attacked with tuberculosis at some time during life, is well recog- 
nized by the medical profession. 

In children living in tenements it is said that by fourteen years 
of age 90 per cent, have acquired tuberculosis. The reason why the 
disease fails to progress in most persons is that the system is strong 
enough to resist it. Tuberculous disease is arrested by the germs 
becoming surrounded by a barrier of healthy tissue, and so perishing 
in their walled-in position. The facts prove that so far from being 
incurable, recovery from consumption is the rule without the patient 
even knowing that he was sick. This is shown by the discovery of 
old healed tuberculous areas (60 to 70 per cent, in the lungs) in 
most persons after death from other diseases. 

It is only those cases which become so far advanced as to be 
readily recognized by anybody that are likely to 'result fatally. 
Many more cases of consumption are cured now than formerly, be- 
cause exact methods have been discovered which enable us to diagnose 
the disease at any early stage of its development. The death rate 

1 This is now reduced to one-ninth in the United States. 



466 DISEASES OF THE AIR PASSAGES 

from tuberculosis in England is 50 per cent, lower than it was forty 
years ago, and in the United States the improvement is as marked. 

Causes. — Consumption is due to the growth of a special germ 
(Bacillus tuberculosis) in the lungs. The disease is communicable 
from a consumptive to a healthy person by means of the germs 
present in the sputum (expectoration) of the patient. The germs 
also escape from the body in the bowel movements, urine, and some- 
times in the sweat. From cows, the disease is chiefly communicated 
by germs in manure falling into the milk. 

The danger of an adult acquiring the disease directly from a 
consumptive patient is slight — if one take the precautions men- 
tioned later in this chapter, except in the case of a person living or 
working in constant close contact with a patient. This is proved 
by the fact that attendants in hospitals for consumptives are rarely 
affected by the disease. Persons in the early stages of consumption 
sometimes have none of the germs in their sputum and in these cases 
the danger of communicating the disease is negligible. 

Consumption is said to be inherited. This is not the case, as 
infants are not born actually bearing the living germs of the disease 
in their bodies, even when born of consumptive mothers. A tendency 
to the disease is, however, seen in certain families and this tendency 
may be inherited in the sense that the offspring has lungs which pos- 
sess less resistance to the growth of the germ of consumption. But a 
still greater danger threatens the infant of consumptive parents in 
that it is directly exposed to the germs of the disease after it is 
born. Infants creep about the floor and put everything into their 
mouths so that, in the case of consumptive parents who are negligent 
about their sputum and personal cleanliness, the child is almost 
certain to acquire the disease. 

Then exposure to the disease in an adult working in an office 
or shop with a consumptive is so dangerous that this question has 
become a part of life insurance examinations. Certain occupations 
and diseases render the individual more susceptible to consumption. 
Thus stone cutters, knife grinders and polishers are more liable to 
the disease through inhalation of irritating dust. Plasterers, cigar 
makers, and upholsterers are next in order of susceptibility for 



COUGH 467 

the same reason, while out-of-door workers are less likely to acquire 
the disease than any other class, with the exception of bankers and 
brokers. 

Among diseases predisposing to consumption are the following: 
colds and bronchitis, influenza, pneumonia, measles, whooping-cough 
and nasal obstruction in causing mouth breathing. The state of 
being generally "run down," having low fever, or pleurisy, is often 
simply the first stage of consumption. 

^o age is exempt, from the cradle to the grave, although the 
liability to the disease diminishes markedly after the age of forty. 
About one-third more women than men recover from consumption 
because it is more practicable for them to alter their mode of life to 
suit the requirements of treatment. 

The neglected cold or cough offers a favorable field for the 
growth of the germs of consumption. A cough or cold lasting a 
month should always lead one to consult a doctor. So also anyone 
who is losing weight, strength, and energy, even if there is no cough, 
should seek medical advice. As it is essential above all else that the 
disease be recognized early, it is necessary that every person should 
know the signs and symptoms which suggest the beginning of con- 
sumption. 

Symptoms. — Cough is the most constant early symptom. It may, 
however, be wholly absent or there may be only a tendency to clear 
the throat frequently, or there may merely be tickling in the throat. 
The cough is more apt to be dry and hacking and more troublesome 
at night and in the early morning. 

Expectoration is a later sign. The sputum should be repeatedly 
examined when there is any suspicion of consumption. All the 
sputum should be collected in a clean, wide-mouthed bottle for three 
days before it is sent for microscopical examination. 

Very important early symptoms are loss of weight, strength, 
energy, and appetite. Patients often come to doctors complaining 
chiefly of loss of energy and interest in their business. Dyspepsia, 
with cough and loss of weight and strength, form a common group 
of symptoms. The patient is pale, has heartburn, nausea or vomit- 
ing, and weakness. There is often a slight rise of temperature in 



468 DISEASES OF THE AIR PASSAGES 

the afternoon, and in women, absence of monthly periods. Every 
person exhibiting the symptoms mentioned should take his tem- 
perature at eight, twelve, four, and eight o'clock. 

A constant temperature in the afternoon of 99.2° to 99.4° F. 
or over, or a constant subnormal temperature (below 98° F.), together 
with a pulse of over 100, and cough, loss of appetite, weight, and 
strength, form a group of symptoms almost certainly indicative of 
consumption, in the absence of other known cause. 

The thermometer should be kept in the mouth for five minutes 
each time, and the temperature should be taken before meals, or at 
least an hour after meals. The highest temperature will be found 
at about four p. m. usually. The pulse, as has been noted, is increased 
in frequency. 

Night sweats are not an early symptom in consumption and 
they occur more often in the early morning hours. However, chills, 
fever, and sweating are sometimes the first symptoms in consump- 
tion, and in a malarial region would probably lead to error, since 
these symptoms may appear at the same intervals as in ague. But 
the fever is not arrested by quinin, as in malaria, and cough, loss 
of weight, not commonly prominent in malaria, are also present. 
Persistently enlarged glands, which may be felt as lumps under the 
skin along the sides of the neck or in the armpits, are also suggestive 
of tuberculosis. 

The spitting of bright red blood with coughing is one of the 
most certain signs of lung tuberculosis, and occurs in about 80 per 
cent, of cases of consumption ; but this is often not an early symptom. 
Bleeding from the lungs usually follows coughing or severe exer- 
cise, but blood may appear in the mouth without any apparent cause 
whatever. 

If the blood is not pure, but if the sputum is simply streaked 
with blood, the chances that the origin may be in the mouth or 
throat are greater. Diseased tonsils in children, and diseased gums 
and teeth in adults, may lead to bleeding. 

In case a patient wakes in the morning and spits blood from 
the mouth it may often happen that the bleeding is from the nose 
and upper part of the throat, especially if the person is subject to 



COUGH 4G9 

nosebleed. Hemorrhage from the mouth from consumption is more 
apt to appear in women at a menstrual period. 

It is a rule that the spitting of blood from the mouth should be 
considered a sign of consumption unless some other origin is evident. 

Pain is also a frequent but not constant early symptom, as 
pain beneath or between the shoulder blades, or in the region of the 
breastbone. The voice is often somewhat hoarse or husky at the 
beginning of consumption. Shortness of breath on exertion is not 
so common an early symptom as later. Prior exposure of the patient 
to tuberculosis would make the symptoms described still more 
suspicious. 

To sum up, one should always suspect consumption in a person 
afflicted with chronic cough, and losing weight, strength, and energy, 
especially if there is a rapid pulse and a slight daily rise in tempera- 
ture, or a constant subnormal temperature. Such a person should 
immediately apply to a physician for general examination, especially 
of the lungs and sputum (expectoration). 

If the germs of tuberculosis are found on microscopical examina- 
tion of the sputum, the existence of consumption is absolutely estab- 
lished. Failure to find the germs in this way does not, on the other 
hand, prove the patient to be free from the disease. In some cases 
examination of both lungs and sputum reveals no sign of the disease, 
while the symptoms make the diagnosis probable. 

There is also a substance called tuberculin, or the poison formed 
by the germs of tuberculosis during their growth, which, when 
injected under the skin in suspected cases of consumption, causes a 
rise of temperature in persons suffering with the disease, but has no" 
effect on the healthy. Persons, however, having practically healed 
tuberculosis may react to the test as positively as those with a serious 
type of the disease, unless minute doses — less than one-sixtieth of a 
grain — are used. Also when the test is positive we know that tuber- 
culosis is present, but it may be in any part of the body. The results 
of tuberculin injection in the consumptive are similar to a very 
short attack of grippe. It is not commonly necessary to make this 
test but in those cases in which the diagnosis is doubtful its use is 
followed by no lasting ill effects when given by a competent doctor. 



470 DISEASES OF THE AIR PASSAGES 

The use of the x-ray in the hands of experts certainly reveals 
the presence of consumption, but it is impossible for the examination 
to distinguish between old healed areas, which are not responsible for 
present symptoms, and recent disease in the lung which is causing 
the symptoms complained of. 

Tuberculosis in Children. — Tuberculosis is the most common 
disease in children. While none is born with it, tuberculosis may 
be acquired soon after birth and is extremely fatal during the first 
two years. After that time the mortality from tuberculosis in chil- 
dren is comparatively slight. 

Tuberculosis in children begins in glands at the base of the 
lungs and in glands elsewhere. Tuberculosis of the lungs is rare in 
childhood, and if present is evidence of advanced disease. 

The symptoms are failure to gain in weight on sufficient food, 
loss of energy, weakness, irritability, loss of appetite and pallor, 
with fever. There may be a dry, throaty cough (which can however 
be caused by enlarged tonsils and adenoids). 

Examination of the chest will rarely reveal the enlarged glands 
at the base of the lungs. X-ray examination is here invaluable 
in showing the enlarged glands in the chest. The simple application 
of a drop of tuberculin rubbed into the abraded skin will surely 
show the presence of active tuberculosis in children of five years 
or younger. By the time children have reached the age of fifteen, 
at least 50 per cent, are afflicted with tuberculosis, and, in tenements, 
90 per cent. Many cases show no symptoms of the disease. 

Children acquire the disease by exposure to tuberculosis in mem- 
bers of the family, or when this can be ruled out, milk is the most 
probable source. About one-quarter of the cases of tuberculosis in 
children arise from milk. It must either be supplied from abso- 
lutely tuberculosis-free cows (always a matter of doubt even in 
certified dairies) or should be pasteurized at home before being 
used (Part II, Chapter II). 

Treatment. — One of the most important matters to decide in con- 
sumption is whether the patient shall be treated at his home or in a 
sanatorium. The sanatorium is much the better place, for a time at 
least, as the patient is drilled in the way of life and care of himself, 



COUGH 471 

not usually possible at home. Those patients who are throwing off 
germs in their sputum should always be treated in a sanatorium 
as they menace all about them. 

In regard to climate the ideal conditions for out-of-door exist- 
ence are pure air and as much sunshine as possible. Dryness, an 
even temperature, and an elevation of two thousand to three thousand 
feet are often most desirable, but not necessary for success. Sana- 
toriums in many parts of the country, and in the vicinity of many 
of the large cities, attain excellent results in early tuberculosis 
without the benefit of special climate. Arizona, New Mexico, Colo- 
rado, the Adirondacks, and some parts of California, contain the 
most favorable climatic resorts in this country. But it is preferable 
for the patient to remain at home under proper treatment in a 
sanatorium than to lead a random life in popular climatic resorts. 
Sanatorium treatment is best anywhere for a time. 

If the patient must stay at home, the following line of treatment 
should be pursued. He should remain out-of-doors all hours of 
bright days — ten to twelve hours in summer and six to eight hours in 
winter — without regard to temperature. He should sleep on a porch, 
veranda or roof out-of-doors. When this is not possible, Dr. Knopf's 
window tent may be used which covers the upper part of the body in 
bed, while enclosing an open window. 

In warm weather a tent may be used with a suitable floor and 
boarded up on the sides a few feet from the ground. The outdoor 
shelter should be large enough (ten by ten feet) for a bed, table, 
and reclining chair, and be capable of being protected on all sides, 
while one or more sides should be kept open at night. A room, 
with even three or four windows, does not give such good results as 
an open outdoor porch protected by canvas curtains, sliding glass, 
or bamboo Venetian blinds. The porch should be on the south side 
or, if this is not possible, the east or west, but the north side of the 
house should not be chosen for winter use. The porch should have 
a sliding glass sash, on the side most exposed to the weather, with 
curtains on the other two sides, and be connected by a door with a 
warm living room from which a bed may be rolled easily onto 
the porch. 



472 DISEASES OF THE AIR PASSAGES 

Two mattresses are desirable in cold weather with paper blanket 
between. A wool horse blanket with its outer side of canvas protects 
the bed in stormy, wet weather. In winter blanket sheets should be 
used and, on the body, a wool undershirt, sweater and outing flannel 
nightgown or bathrobe are worn in sleeping. In addition, in very 
cold weather woolen socks and drawers may be used. A hot water 
bag wrapped in flannel should be placed in the bed before retiring 
in cold weather. 

It is better for the patient to get into bed in a warm room and 
be rolled outdoors when possible. Blankets or comforters should 
be tucked under the bed pad fa folded blanket), which is placed on 
top of the upper mattress, but the outermost cover should be tucked 
under the upper mattress to make the bed secure and warm. The 
head of the bed must be protected from wind by being placed against 
a wall, or the head of the patient may be protected by a canvas 
shield like a buggy top. One may wear a knitted helmet covering 
the whole head and neck, with the exception of a small hole for 
the nose and mouth, or a kind of sunbonnet made of many thick- 
nesses of flannel. Cold cream on the face and lips will prevent 
chapping, and a piece of flannel may be held over the nose by a strip 
of adhesive plaster. 

For sitting out in cold weather, in addition to the ordinary 
clothes and sweater, a fur coat is most useful and fur or heavy 
woolen mittens. Two or more loose, heavy, wool socks with felt 
shoes and foot muffs should protect the feet. A heavy blanket may 
be placed on a steamer chair and wrapped about the patient, and the 
whole covered with a steamer rug. Xo one should remain out when 
chilled; when this occurs the patient should go into a warm room 
and take a glass of hot milk. 

If a patient is weak or feverish he should remain in bed or on a 
couch, or on a porch during the day. and in a room with many open 
windows at night, so that there will be a good draught through the 
room. The patient may be protected by screens. Such symptoms 
as cough, fever, night sweats, or spitting of blood should not be al- 
lowed to interfere with the fresh air treatment. Only the most se- 
vere cold and stomas may be permitted to drive the patient in. 



COUGH 473 

During the first month of treatment the patient should take very 
little exercise, and none at all if there is fever. If on taking the 
temperature an hour after walking it is found to be above normal, 
and the pulse is over eighty- five, all exercise should be avoided 
for a time. 

Nutritious food is of equal value with the open air life. A 
liberal diet of milk, cream, eggs, meat, and vegetables is advised. A 
glass of milk with each of the three meals, and a glass containing 
a mixture of equal parts of cream and milk in the middle of the 
morning, afternoon, and at bedtime, are to be recommended. In 
place of the milk and cream, two eggs beaten with a little sherry may 
be taken by way of variety. 

If the appetite is very poor it is best that a glass of milk be 
taken every two hours, varied by beaten eggs with sherry, or a few 
tablespoonfuls of juice squeezed from rare beef. Gain in weight is 
usually the most favorable sign but in some cases, when the patient 
is well nourished, this is not essential. To prevent constipation the 
patient may take liquid albolene or agar and bran. 

Drug treatment depends upon individual symptoms and there- 
fore can only be given under a physician's care. The same applies 
to the only special treatment known, that of tuberculin. Many 
patients are much benefited by tuberculin given by an expert. Given 
otherwise it may do much harm. Recently the injection of nitrogen 
gas into the space surrounding the lung has given good results in 
some cases, but this treatment cannot be readily done at the patient's 
home. 

The outdoor treatment is possible even in cities but, for patients 
living out of town, it frequently gives excellent results when the 
subject is under a doctor's care. For those not able to go to a 
sanatorium or take advantage of a change of climate there is much 
more hope than formerly. 

In tuberculosis in children when the glands are chiefly affected, 
and often those at the root of the lungs, outdoor sleeping, and keep- 
ing the child outdoors in the day also, will accomplish wonders. The 
child should take daily a pint of half milk and half cream, between 
meals, and a glass of rich milk, with beef juice, eggs, and meat, at 



474 DISEASES OF THE AIE PASSAGES 

meals. A child may attend the outdoor schools, which are now 
quite common, after improvement has begun. The tuberculin treat- 
ment of children gives excellent results in the hands of an expert. 
It is rarely necessary to send a child with early tuberculosis to a 
sanatorium. 

Prevention. — Weak children and those bom of consumptives 
must receive a generous diet of milk, cream, eggs, meat and vege- 
tables, and spend most of their time out-of-doors during the day and 
sleep out-of-doors at night. The milk should all be pasteurized at 
145° F. for thirty minutes. 

If one of the family is tuberculous, and discharging the bacilli 
in the sputum, the home is not a safe place for a child. The same 
applies to children with actual tuberculosis of the lung; they are a 
special menace to others and can be treated most satisfactorily in a 
sanatorium. 

This condition is, however, rare in childhood. A consumptive 
adult should have a separate sleeping room and refrain from caress- 
ing or kissing others. All dishes and eating utensils used by a 
consumptive should be boiled after use. The sputum should be 
received in paper bags or boxes made for the purpose, which should 
be burned before the contents dries. Out-of-doors the sputum may 
be deposited in a wide-mouth bottle, the contents of which is placed 
in a fire, and the bottle should be boiled. The use of rags, paper 
napkins, and handkerchiefs is unwise. 

The sputum is practically the sole medium of contagion in 
adults, and if it is properly cared for there is little danger to adults 
in contact with the patient. When a consumptive has no sputum or 
there are no bacilli discharged in the sputum, there is no danger of 
contagion. In young children with tuberculosis of the lung, the 
sputum is swallowed and the bowel discharges must be carefully 
disinfected. 

Xo dusting should be done in a consumptive's room — only moist 
cleansing. Plenty of sunshine in a room will cause destruction of 
the germs of consumption beside proving beneficial to the patient. 
In persons having bacilli in their sputum the fine spray emitted in 
coughing and sneezing disseminates germs into the surrounding air. 



COUGH 475 

ASTHMA 

Asthma is a state of difficult breathing due to disturbance of 
the nerves controlling the caliber of the smaller bronchial tubes 
in the lungs. Attacks often begin suddenly, owing to partial clos- 
ure of the bronchial tubes from spasm, and also from swelling due 
to congestion — as may be seen in the nose in the closely allied disease 
— hay-fever. 

Causes. — The chief cause of asthma is disease in the nose, cavi- 
ties in the head connecting with the nose, and in the throat. When 
such existing conditions as obstructions in the nose, adenoids, en- 
larged tonsils, polypus, etc., are removed by the throat specialist, 
and the resulting catarrh cured, it will be found that the asthma 
will also be cured in most cases. Colds and coughs also favor 
asthma but these are frequently secondary to the causes noted. 
The disease may be of purely nervous origin in some cases. 

In susceptible persons, that is, those having chronic disease in 
the nose and throat and the peculiar nervous organization favoring 
asthma, attacks may be brought on by emanations from animals 
(horses, dogs, and cats), by the pollen of flowers and hay, and by 
dust and heat. 

It is common knowledge that the most extraordinary circum- 
stances provoke attacks of asthma in the susceptible, such as slight 
changes of air, which may be found in rooms of the same house, 
and in the same city. That is, a patient may have asthma in one 
story of a house and not in another, or in one part of a city and 
not in another. Overeating and dyspepsia favor the disorder; also 
emotion, fright, changes in temperature, and change of residence. 

Asthma occurs in males (in 66 per cent, of cases) between 
childhood and forty, especially in nervous, weakly, anemic persons 
subject to rickets or tuberculosis. It is known that asthmatics may 
be badly affected by diphtheria antitoxin. 

Symptoms. — Attacks are sudden, and occur more often at night. 
Sometimes there are warning signs, as cold in the head, chilly feel- 
ings, tightness in the chest, mental depressions, etc. Breathing 
suddenly becomes difficult ; there is a feeling of weight on the 



476 DISEASES OF THE AIR PASSAGES 

chest ; the patient fights for breath. He may go to an open window, 
and draw in .air with great difficulty while the expiration is pro- 
longed and wheezy. The face grows pale, anxious, and covered 
with sweat; the feet and hands cold, and the lips blue; speaking 
may be impossible and the voice is faint and hoarse. Just as the 
patient appears to be suffocating the attack may subside with cough- 
ing and spitting of minute sticky balls of mucus in a thinner se- 
cretion. 

The attacks may last but a few minutes, or one to two hours, 
and return at long or short intervals. No death has ever been re- 
corded during an attack of asthma, although the disease appears 
most alarming. After many seizures the breathing may be wheezy 
and short much of the time, and chronic bronchitis is usually 
present. 

The outlook is uncertain; sometimes attacks occur from child- 
hood to old age but may cease at any time, particularly if the cause 
can be discovered and removed. 

Treatment. — During an attack nothing gives such rapid and 
sure relief as a hypodermic injection of one-quarter grain of mor- 
phin, which should be given by a physician. AYhen a doctor is not 
available the patient may break one of the glass pearls containing 
three drops of amyl nitrite in the handkerchief and inhale the drug 
with immediate relief. Prompt arrest of an asthmatic paroxysm 
is often secured by inhalation of chloroform. For the patient to 
do this safely he must rinse the inside of a tumbler with chloro- 
form, pour the chloroform back into the bottle and cork it, and 
then inhale the chloroform from the tumbler. This may be repeated 
a few times. 

A drink, containing four tablespoonfuls of hot water and whisky 
and a teaspoonful of spirit of chlorofomi, is often efficacious, or 
whisky alone in those not accustomed to it. A cup of strong coffee, 
smoking a cigar or cigarette of tobacco (in non-smokers) or those 
made especially for asthma (as cigarettes d'Espic) may also be 
tried. The application of a paste of Coleman's mustard (one part 
mustard and three parts flour) between two layers of thin muslin 
to the chest will aid in arresting an attack of asthma. 



COUGH 477 

Between the attacks a combination of potassium iodid and 
strontium bromid (each ten grains, three times daily in half a 
glass of water after eating) is the most efficient remedy. To avoid 
the continuance of asthma it is emphatically advisable to consult 
a physician who may be able to discover and remove the cause. 

The diet should consist chiefly of eggs, fish, milk, and vege- 
tables (with the exception of beans, large quantities of potatoes, and 
roots — as parsnips, beets, turnips, etc.). Meat should be eaten 
but sparingly; also nuts, pickles, hard boiled eggs, cheese, pork, 
pastries, sugar, and starches (as cereals, potato, and bread). The 
evening meal ought to be light, dinner being served at midday. 

Any change of climate may stop asthmatic seizures for a time, 
but the relief is apt to be temporary. Climatic conditions affect 
different patients differently. Warm, moist air in places destitute 
of much vegetation (as Florida, the Bermudas, West Indies, South- 
ern California, the shore of Cape Cod, and the Island of Nantucket, 
in summer) enjoy popularity with many asthmatics, while a dry, 
high altitude influences others much more favorably — as the Adi- 
rondacks. 

HAY-FEVER 

Cause — The sole cause of this disease, but recently discovered, 
appears to be pollen — owing to its mechanical (sharp projections on 
pollen) and chemical (poison, toxalbumin) irritation of the mucous 
membrane of the nose and eyes. There is enough of the poison in 
two pollen grains to affect sensitive' persons. Early cases in May 
and June (rose cold) are 'due to the pollen of the grass family (in- 
cluding the grains). 

The true hay-fever of late summer is due to pollen of weeds, and 
eighty-five per cent of cases to ragweed. Pollen is carried by in- 
sects and wind. The pollen of inconspicuous flowers, or weeds, is 
abundant and wind-blown and the source of hay-fever. The pollen 
of showy, honeyed flowers is smaller in amount and conveyed by in- 
sects to other flowers. Pollen may be blown in sufficient quantity a 
half mile to cause hay-fever in susceptible subjects. 

The disease is twice as common in males as in females, and is 
inherited in a large percentage (33 per cent.) of cases. In early 



478 DISEASES OF THE AIR PASSAGES 

summer it is sometimes called rose cold, and in August and Sep- 
tember it is known as hay-fever. It terminates immediately after 
the first frost. In the Southern States it is present all the year. 

Hay-fever prevails among those between fifteen and thirty years 
of age and in the educated and highly nervous. A peculiar sus- 
ceptibility of the nasal mucous membrane to the irritation of pollen 
seems to exist, especially if there are abnormalities in the nose, 
as polypi, spurs, and enlargement of the turbinates in the nose. 

Symptoms. — The disease begins like a common cold in the head, 
but there is more bodily depression and often fever of 100° to 
101° F. Light hurts the eyes, which are inflamed, red, and weep- 
ing, and the nose is frequently red also. Headache is common, 
and sneezing and cough increase the distress. Asthma sometimes 
accompanies or follows an attack of hay-fever. A return of the 
trouble is probable, but the disease usually disappears as age ad- 
vances. 

Treatment. — General treatment includes the use of tonics to the 
nervous system, such as capsules, each containing one-thirtieth of 
one grain of arsenic trioxid and one-sixtieth of one grain of strych- 
nin sulphate — one to be taken three times daily after meals. Cold 
baths or cold sponging daily are also of service. As light hurts 
the patient's eyes, exercise should be taken out of doors morning 
and evening and dark glasses will protect the eyes to some extent. 

Local treatment must be given by an expert in nose and throat 
diseases and the use of a .cautery or removal of growths may 
give much relief. The frequent spraying of the nose with Seller's 
solution and, following this, with a spray of albolene containing 
fifteen grains of menthol and camphor to the ounce, will usually 
afford comfort. Sometimes the spraying of a solution of adrenalin 
(1 part in 5,000 of water) in the nostrils will arrest the disease by 
contracting the blood vessels. This may be done several times daily. 

Special treatment with horse serum, which has been obtained 
from animals injected with the poison in pollen, is used in the form 
of powder sold as pollantin, and this may be applied to the nose in 
the morning, after sleeping with closed windows at night — to keep 
out pollen in the air. The effects of pollantin vary much, many 



COUGH 479 

patients being greatly improved by it, while in some the condition 
is aggravated. 

When the disease is not being cured by local treatment, and for 
all patients who can manage it, a change of residence is advisable. 
In the Eastern States, the Adirondacks and White Mountains are 
favorite resorts, also barren islands, like the Isles of Shoals. In 
the West, Banff, in the Canadian Rockies, is most highly recom- 
mended, while in Europe many places are to be found, among which 
Heligoland is perhaps the most popular for this disease. The 
object is to be rid of the presence of pollen from vegetation and 
to get into a bracing climate. There is no other disease which 
so quickly yields to change of climate as hay-fever. 

The destruction of weeds (especially ragweed) is the most im- 
portant means of preventing hay-fever. Laws to enforce the destruc- 
tion of many common weeds (as the thistle, burdock, yellow dock, 
daisy and wild carrot and mustard) now exist in ten states. 



INFLUENZA 

{La Grippe) 

Influenza is an acute, highly contagious disease due to a special 
germ, and tending to spread with amazing rapidity over vast areas. 
It has occurred as a world-wide epidemic at various times in history, 
and during four periods in the last century. 

A pandemic of influenza began in the winter of 1889-90, and 
continued in the form of local epidemics till 1904, the disease sud- 
denly appearing in a community and, after a prevalence of about 
six weeks, disappearing again. One attack, it is perhaps unneces- 
sary to state, does not protect against another. 

The mortality is about one death to four hundred cases. The 
feeble and aged are apt to succumb. Fatalities usually result from 
complications or sequelae, such as pneumonia or tuberculosis. Neu- 
rasthenia or insanity may follow. 

Symptoms. — There are commonly four important symptoms 
characteristic of grippe: fever, pain, catarrh, and depression — 
mental and physical. Grippe attacks the patient with great sud- 



DISEASES OF THE AIR PASSAGES 

denness from one to three days after exposure to the contagion. 
While in perfect health and engaged in ordinary work, one is seized 
with a severe chill followed by general depression, pain in the head, 
back, and limbs, soreness of the muscles, and fever. The tempera- 
ture varies from 100 : to 104 : F. 

The catarrh attacks the eyes, nose, throat, and larger tubes in 
the lungs. The eyes become reddened and sensitive to light, and 
movements of the eyeballs cause pain. Sneezing comes on early. 
and. after a day or two, is followed by discharge from the nose. 
The throat is often sore and reddened. There may be a feeling of 
weight and tightness in the chest accompanied by a harsh, dry- 
cough, which after a few days becomes looser, and expectoration 
occurs. Bodily weakness and depression of spirits are usually 
prominent, and form often the most persistent and distressing symp- 
toms. 

After three or four days the pains decrease, the temperature 
falls, the cough and oppression in the chest lessen, and recovery 
usually takes place within a week or ten days, in ordinary eases. 

The patient should go to bed at once, and should not leave it 
until the temperature is normal (98% c E. . For some time after- 
wards general weakne-. ; - eiated with heart weakness, causes the 
patient to sweat easily, and to get out of breath and have a rapid 
pulse on slight exertion. 

Such is the picture of a typical case, but it often happens that 
some of the symptoms are absent, while others are exaggerate 
that different types of grippe are often described. Thus the pain 
in the back and head may be so intense as to resemble that of menin- 
gitis. Occasionally the stomach and bowels are attacked so that 
violent vomiting and diarrhea occur, while other members of the 
same family present the ordinary form of influenza. There 
form that attacks principally the nervous system, the nasal and 
bronchial tracts escaping altogether. Continual fever is the only 

iptom in some case-. Grippe may last for wee! 

Whenever doubt exists as to the nature of the disorder, a micro- 
scopic examination of the expectoration or of the mucus from the 
throat by a competent physician may definitely determine the ex- 



COUGH L8J 

istence of influenza, if the special germs of that disease are found, 
to be predominant. 

It is the prevailing fashion for persons to call any cold in the 
head the grippe; and there are, indeed, many cases in which it 
becomes impossible for a physician to distinguish between grippe 
and a severe cold with muscular soreness and fever, except by 
the microscopic test. Thus u colds" or infections of the nose and 
throat with pneumonia germs (pneumococcus), the germ of nasal 
catarrh (Micrococcus catarrhalis) or the ordinary germs infecting 
wounds (staphylococci), may only be differentiated from grippe 
by microscopical examination of the secretion of the nose and throat. 
The treatment would be the same, however, as for grippe. 

The mere presence of certain germs in the nose and throat does 
... 
not necessarily indicate that they are responsible for existing dis- 
ease. Many healthy persons carry about grippe germs for long 
periods after grippe epidemics. These carriers are sometimes re- 
sponsible for fresh outbreaks of grippe. 

Influenza becomes dangerous chiefly through its complications, 
as pneumonia, inflammation of the middle ear, of the eyes, or of the 
kidneys, and through its depressing effect upon the heart. 

These complications can often be prevented by avoiding the 
slightest imprudence or exposure during convalescence. Elderly 
and feeble persons should be protected from contact with the disease 
in every way. Whole prisons have been exempt from grippe during 
epidemics, owing to the enforced seclusion of the inmates. The one 
absolutely essential feature in treatment is that the patient stay 
in bed while the fever lasts and in the house afterwards, except 
as his strength will permit him to go out of doors for a time each 
sunny day, until recovery is fully established. 

Treatment. — The patient should be isolated in a room by him- 
self. The discharges from his nose and throat should be burned, 
and the nose and throat should be sprayed several times daily with 
a good antiseptic, as Dobell's solution. 

The medicinal treatment consists at first in combating the toxin 
of the disease and assuaging pain, and later in promoting strength. 
Hot lemonade and whisky may be given during the chilly period 



DISEASES OF THE AIB PASSAGES 

and a single six- to ten-grain dose of quinin. Only mild cathartics 
are suitable to keep the bowels regular, as a Seidlitz powder in 
the morning before breakfast. 

The diet should be liquid while the fever lasts — as milk, cocoa, 
soups, egg nog — one of these every two hours. A tablespoonful of 
whisky, rum, or brandy may be added to the milk three times daily 
if there is much weakness. 

The germ causing grippe lives only two days, but sueeessrro 
crops or spores are raised in a proper medium. Xeglected mucus 
in nose or throat affords an inviting held for the germ; therefore 
it is essential to keep the nostrils free and disinfected by spraying 
with Dobell's or Seiler's solution. It is extremely important that 
elderly persons, or those with weak hearts, should remain quiet 
in the house for some time after apparent recovery, as heart failure 
and death are not uncommon without such care. 

In some cases many weeks are required before health is com- 
pletely restored and often a trip to a more salubrious :.:_ ate is 
advisable. Prolonged mental depression following grippe is one of 
its most well-known and unfortunate features. 



CHAPTER XII 

DISEASES OF THE HEART, THE BLOOD, AND THE BLOOD 

VESSELS 

Heart disease. Palpitation of the heart. Anemia. Arteriosclerosis. 



DISEASES OF THE HEART 

HEART DISEASE 

The heart is a hollow muscle which withdraws blood from one 
set of blood vessels (the veins) and pumps it into another set (the 
arteries), and thus keeps the blood moving about the body. Within 
the heart are chambers and valves to prevent the blood from flowing 
back from the arteries into the heart and from the heart into the 
veins, as the valves in a pump prevent the water from flowing back 
into the well when the piston is raised. 

In heart disease the heart muscle is either altered in structure 
through the influence of poisons — most of which are produced by 
the germs of infectious diseases — or the valves of the heart become 
defective, owing to attack by germs, do not close properly and are 
leaky, or else become obstructed. Such defects constitute what is 
called "valvular disease," which is the most common form of chronic 
diseases of the heart. The effect of such a condition is that the 
heart does not pump sufficient blood into the arteries, because it 
leaks back into the veins. 

But there is a common provision of nature which frequently 
prevents such a disturbance, and this consists in enlargement of 
the heart and increase in its muscular power sufficient to overcome 
the valvular defect. When this happens, there may be so little dis- 
turbance produced by disease of the valves that the patient may be 

483 



484 DISEASES OF THE HEART AND BLOOD 

entirely ignorant of its existence. This effort of nature is called 
"compensation," and it may be more or less perfect and may last 
a longer or shorter time. 

Occasionally a person may live to a good old age with a valvular 
affection of the heart which has been prevented from giving any 
trouble by the compensatory enlargement. When the enlargement 
is insufficient, or when after a time the increase in muscular power 
caused by the enlarged heart ceases, then disturbances in the cir- 
culation appear, and are manifested by symptoms. 

Causes. — Among all the acute diseases, rheumatic fever is the 
most frequent source of heart disease. Scarlet fever, tonsillitis, 
pneumonia, smallpox, erysipelas, blood poisoning, gonorrhea, child- 
bed fever, etc., are often responsible for disease of the heart — either 
evident at the time or occurring at a later period. While children 
may be born with heart defects, rarely is the tendency to heart 
disease inherited. 

Habitual use of alcohol, syphilis, Bright's disease of the kidneys, 
and gout favor its occurrence. Repeated mental stress or physical 
overstrain favor the development of some forms of heart disease. 
Heart disease attacks all ages and both sexes. Valvular disease 
begins more frequently between the ages of eighteen and forty, 
and is a little more frequent in women. Arteriosclerosis, or hard- 
ening of the arteries, leads to disease of the heart in middle life. 
To sum up we may say that there are five usual causes of heart 
disease: in youth and in early adult life (1) acute tonsillitis and its 
accompanying rheumatism; in young adult and middle life (2) 
syphilis, (3) Bright's disease of the kidneys, and (4) goiter; in 
middle and advancing years (5) arteriosclerosis (Cabot). 

Persons of middle age or past middle age sometimes feel dis- 
comfort or pain in the region of the breastbone, and the pain may 
extend into the neck or left arm. This trouble is usually thought 
to be due to indigestion, as the pain may be near the stomach. If 
the pain does not appear after eating, but only is felt after exertion, 
as in going upstairs, uphill, or in running, or is brought on by emo- 
tion — especially if there is shortness of breath — one should consult 
a doctor in reference to the condition of the heart. 



DISEASES OF THE HEART 485 

Symptoms. — Shortness of breath on slight exertion; blueness 
of the lips, finger tips, face, and ears; and swelling of the feet 
are among the more common symptoms. Discomfort, pains, and 
palpitation of the heart, with indigestion, cough, dizziness, and faint- 
ing, are also symptoms. There may rarely be spitting of blood. 
Xot all these symptoms are present in all cases of heart disease, 
and any single one of them may be characteristic of some other 
disorder. 

In children paleness and unnatural inactivity — the child does 
not run about and play like other children — are usually observed. 
There is shortness of breath, blue lips, complaint of distress or 
pain about the heart, and it may be seen or felt beating violently. 
The digestion is disturbed, the feet may swell, or the child may 
be unable to lie flat and breathe comfortably. 

A careful, physical examination of the heart and body, made by 
a physician, is essential whenever heart disease is suspected. It is 
impossible to form any correct opinion concerning its existence from 
the symptoms alone. Pains about the joints in children with or 
without fever should always lead parents to secure medical advice 
in the light of a possibility of rheumatism and its common result 
in leading to damage of the heart. What are improperly called 
"growing pains" are gouty or rheumatic danger signals. 

Treatment. — It is impossible to outline any form of treatment 
which must vary according to the kind of heart disease and the 
individual needs. From what has been said of the frequency with 
which disease of the heart originates in the acute diseases, as grippe, 
diphtheria, pneumonia, tonsillitis, etc., the necessity of patients 
remaining in bed for a sufficient length of time to save the heart, 
and the importance of keeping the patient quiet in bed, and not 
allowing him to sit up during such diseases, will become evident to 
the reader. 

Avoidance of excitement and exposure is important after at- 
tacks of rheumatic fever and of the infectious disorders. The diet 
should be moderate and distention of the stomach should be avoided ; 
alcohol and tobacco must be forbidden absolutely. A patient suf- 
fering from heart disease should never drink large quantities of 



486 DISEASES OF THE HEART AND BLOOD 

fluid at one time or during the day: one-half to two-thirds of a 
glassful of fluid may be taken at one time. 

Sudden death from failure of the heart is very rare, and the 
prevalent fear of such failure is unfounded. 

PALPITATION OF THE HEART 

Symptoms. — A test of the normal condition of most of our or- 
gans is our unconsciousness of their existence. In palpitation of 
the heart its movements become uncomfortably perceptible, and 
there is an indescribable discomfort or distress over the heart; more 
commonly there is a beating, throbbing, fluttering, or jumping 
sensation. At the same time there may be a feeling of "goneness" 
and weakness in the pit of the stomach, or nausea with pains about 
the heart. 

Causes. — Palpitation is usually due to nervous weakness, and 
occurs more frequently in nervous and anemic women. While in 
some cases the action of the heart is rapid and violent, in other 
cases it beats naturally and quietly when the patient imagines it is 
beating tumultuously. This shows that the condition arises often 
from unnatural sensitiveness of the patient to the action of the 
heart; for in true organic disease of the heart muscle, when the 
action is unusually strong or rapid, the patient is, in most instances, 
completely unconscious of it. Palpitation is then generally not a 
symptom of serious heart disease, but is usually significant of nervous 
weakness which usually admits of cure, although in some persons 
the trouble may persist for a long period. 

Palpitation is not continuous, but there are intervals of free- 
dom from distress. The attacks may last for a few minutes or even 
for an hour or more. Palpitation is seen often in women at puberty, 
during menstrual periods, or during the "change of life," when the 
nervous system is more sensitive. Fright, excitement, grief, and 
anxiety may occasion it. In men, excess of alcohol, coffee, and 
tobacco, and in women, tea, are frequently responsible for palpitation. 

Indigestion with wind or flatulence is a common cause. Over- 
work, nervous exhaustion, hysteria, and sexual excitement favor its 
occurrence. Palpitation is more apt to appear when the body as- 



DISEASES OF BLOOD AND BLOOD VESSELS 487 

sumes certain postures, as lying on the left side. Exercise not 
rarely relieves palpitation. During an attack the increased action 
of the heart may be seen or felt with the hand on the chest, the 
face may be red, and the pulse rapid. In other cases — as has been 
noted — no change can be detected. 

Treatment. —The attack may be relieved by a teaspoonful of 
spirit of chloroform (not pure chloroform), or one-half teaspoonful 
of Hoffman's anodyne, or a teaspoonful of tincture of valerian — 
one of these in a wine glass of water. A half teaspoonful of aro- 
matic spirit of ammonia, or a little brandy, in cold water may be 
serviceable also. The brandy is not suitable for those accustomed 
to alcohol. 

Tea, coffee, tobacco, alcohol, and sexual excitement must be 
avoided. The taking of a regular, moderate exercise, of ten hours' 
sleep, and of daily tepid or cool baths, with light meals, should be 
the rule. Other existing disorders which may be responsible for 
the palpitation, as nervous exhaustion, should receive medical at- 
tention. An examination of the heart by a physician is essential 
to eliminate absolutely the possibility of true organic diseases of 
the heart. 

Treatment of a tonic nature with iron and strychnin, which 
can only be prescribed to advantage by the medical man, should 
generally be continued for some time. The application of a mus- 
tard paper, or cold compress, over the heart during the attacks will 
sometimes prove of value. The hourly use of sodium bromid taken 
in five-grain doses dissolved in one-half a glass of water, is one of 
the most useful remedies for nervous persons, but should not be 
continued for a longer period than a day at a time. 



DISEASES OF THE BLOOD AND BLOOD VESSELS 

DEFICIENCY IN QUANTITY OR QUALITY OF THE BLOOD 

(Anemia) 

Blood is a fluid in which float microscopic solid elements — the 
red and white cells. 



488 DISEASES OF THE HEART AND BLOOD 

Anemia is a condition of the blood in which either the total 
amount of blood is reduced, or there is a deficiency in the number 
of red cells, and in iron, which gives to these cells their red color. 
Until the microscopic examination of blood had reached the devel- 
opment which it now has attained, a person was thought to have 
anemia when the face — and particularly the lips — presented a pale 
or bloodless color. But the examination of the blood shows 
us that not all persons with pallor to a marked degree have anemia. 
This is notably the case with persons living in the tropics (who 
are not exposed to the sun), in those with nervous exhaustion, in 
some cases of heart disease, in morphin habitues, and often in 
patients with beginning consumption. Some healthy persons are 
always pale. Therefore it is not safe to rely upon color or even 
symptoms — as in nervous prostration with pallor we have symp- 
toms common to anemia; for accuracy the blood of the pale person 
must be examined by a competent medical man. 

Anemia is ordinarily secondary to some other diseased condi- 
tion. Among these we have the following: loss of blood as from 
wounds, from bleeding from the stomach, lungs, piles, or from 
the womb; in conditions with a constant drainage from the body, 
as in nursing mothers, in chronic diarrhea ; with discharging sores 
or wounds; poisons, as constant exposure to lead and arsenic, poi- 
soning in Bright's disease, and the poisons of germ diseases, as ma- 
laria, syphilis, typhoid fever, tuberculosis, etc. ; chronic digestive 
disorders, or starvation and cancer. Various forms of worms in- 
festing the bowels may produce the most severe forms of anemia, 
and among these the minute hookworm has recently been discovered 
to be responsible for much of the disease in certain localities, as in 
our insular possessions in the Philippines and Porto Rico and in 
many parts of the Southern United States. The "clay eaters" of 
the South owe their color and condition chiefly to the hookworm. Its 
recognition and expulsion from the body have now become simple 
matters to the physician. 

It will thus be impressed upon the mind of the reader that it is 
incumbent upon pale persons not only to have their blood examined 
but to employ a physician to discover and remedy the cause. There 



DISEASES OF BLOOD AND BLOOD VESSELS 489 

are, however, certain individuals in whom it may not be possible 
to assign a cause, and there are two general classes of cases in 
which there is severe anemia without apparent cause. These two 
classes include (a) the "green disease" (chlorosis) of young women 
between the ages of fourteen and seventeen — generally those who 
have grown up in the city without proper air, food, and exercise, and 
who present a peculiar yellowish-green complexion; and (b) the 
fatal type of anemia, in which there is waxy pallor and bloodless 
lips and such great languor and increasing weakness that the patient 
is forced to remain in bed. 

Symptoms. — Besides paleness of the skin and mucous membrane 
of the lip inside of the mouth and pearly whiteness of the whites 
of the eyes, there is the peculiar greenish-yellow complexion of the 
anemia of young women. In the more grave forms the skin has 
often a waxen or even yellowish hue, and there may be brown pig- 
mentation about the ankles. 

Among the more frequent results of anemia are fluttering of 
the heart and short breath on slight exertion; languor and fatigue 
after mental or physical work ; poor appetite and disturbed digestion, 
with chronic constipation; headache, dizziness, and fainting, with 
the appearance of spots before the eyes and blurring of the sight. 
Cold feet and hands are frequently present. In severe cases of 
anemia there is excessive weakness; puffiness of the face and ankles 
are sometimes seen. 

The skill of a physician will be required to rule out such condi- 
tions as disease of the heart or kidneys, or nervous exhaustion asso- 
ciated with paleness, in which the symptoms are somewhat similar. 
The outlook is usually favorable in the anemia secondary to other 
diseases, which can be remedied, and also in the form of "green 
disease" peculiar to young women. 

Treatment. — The treatment consists, in a general way, in fol- 
lowing an out-cloor life, especially in high altitudes ; in eating good, 
nourishing food, particularly meats, milk, eggs, and green vegetables ; 
in having a good movement of the bowels daily by means of a tea- 
spoonful (more or less) of Epsom salts in a glass of cold water on 
rising, and in the use of iron in the form of Blaud's pills. Two 



490 DISEASES OF THE HEART AND BLOOD 

of the five-grain Blaud's pills may be taken three times daily, after 
meals. Arsenic is valuable, notably in the more severe cases, but 
should be taken only under the physician's directions. 



DEGENERATIVE CHANGES OF AGE 

ARTERIOSCLEROSIS 

(Hardening of the Arteries) 

Cazalis said : "A man is as old as his arteries." This is now 
an axiom in medicine. Arteriosclerosis, while it means hardening of 
the arteries, also means thickening of the arteries and lessening of 
their caliber so that a greater pumping force of the heart is required 
to distribute the blood through the vessels. 

This disease of the arteries is four times more common in men 
than in women. It occurs usually after fifty in men and a decade 
later in women. The change in the vessel is due to overwork of the 
vessels. The arteries which are worked the hardest are the first to 
become diseased. Thus in the manual worker, the arteries in the 
arms and legs are thickened; in the mental worker the arteries in 
the brain and heart are chiefly affected. 

The function of arteries is to dilate and contract. When such 
changes are too excessive, and occur too frequently, or for too long 
a period, hardening is apt to follow. 

We think of the heart as never stopping, but the heart sleeps longer 
than the brain. This is explained by the heart's rest periods which 
alternate with its contractions or beats. When the times occupied 
by the rest periods are added together, we find that the heart rests 
thirteen hours and works eleven hours out of the twenty-four. Xow 
during the rest periods of the heart the circulation is carried on by the 
elastic recoil of the arteries, which dilate during the contraction of 
the heart, but contract during the rest period of the heart, when 
that organ is filling with blood. The arteries, therefore, act as 
veritable motors. By means of the nervous system the arteries regu- 
late the supply of blood to a part — as seen in the flushing or pallor 
of the skin. There is never enough blood to fill all the blood vessels 



DEGENERATIVE CHANGES OF AGE 491 

at the same time throughout the body. The nervous system is the 
stopcock which, by dilating or contracting the arteries, apportions the 
amount of blood needed by different organs in the body at any given 
time. 

In physical or mental work, excitement or worry, the vessels di- 
late — in the limbs in physical work, in the brain in mental activity 
by increased action of the heart. Contraction is necessary to restore 
the caliber of the arteries, and when this elastic power gives out nature 
tries to compensate by causing thickening of the arteries through a 
growth of new tissue in them. 

Causation.- — In the manual laborer hard physical work will cause 
arteriosclerosis, but as it is more apt to occur in the limbs, it is not so 
dangerous. In men in easy circumstances, overeating, hard drink- 
ing, and excessive smoking, with too little exercise, are common 
causes. Most men over forty, and in good circumstances, overeat. 
Obesity favors thickening of the arteries by obstructing the vessels 
and by putting too much work on them and the heart in overcoming 
the obstruction. One hears much now-a-days about high blood 
pressure. High blood pressure may ultimately lead to thickening of 
the arteries in nature's attempt to strengthen the blood vessels. Again, 
thickening and narrowing of the arteries increases blood pressure — 
a vicious circle. 

Blood pressure is measured by the amount of pressure which 
is required to obliterate an artery so that its pulsations cease. It actu- 
ally means the pressure exerted by the blood against the walls of 
the blood vessels. The arteries in the abdomen are chiefly respon- 
sible for the state of blood pressure, as they act as a reservoir of 
blood. 

Since these vessels are rarely thickened by disease it happens 
that blood pressure may not be necessarily high in arteriosclerosis. 
Indeed, according to Sawada, only twelve per cent, of cases of arterio- 
sclerosis have high blood pressure, excluding those with kidney 
disease. 

High blood pressure is a warning, as in time it may lead to thick- 
ening of the vessels and damaged heart and kidneys. Every individ- 
ual over forty should have occasional examination of his blood pres- 



49? DISEASES OF THE HEAET AXD BLOOD 

sure by his family physician. If a thorough, general examination 
of the body were made annually, of all persons over forty-five, life 
could be much prolonged. ATany cases with high blood pressure can 
recover perfect health by proper living. Certain diseases causing 
poisons in the blood, as typhoid fever, syphilis, and gout, provoke 
arteriosclerosis. 

Poisons generated by delay of the intestinal contents ('stasis) in 
constipation induce the disease. There is great difference of opinion 
regarding the influence of alcohol and tobacco in causing hardening 
of the arteries. It is simply a question of how much harm they do. 

Some persons inherit strong tubing or vessels : these are apt to 
achieve longevity. In others the reverse is true, although most cases 
of arteriosclerosis are due to abuse of good blood vessels. 

The quiet life with moderate eating and drinking tend to prevent 
the change, but with old age. arteriosclerosis is natural and to a 
certain extent conservative in compensating for the loss of elas- 
ticity of the vessels. Worry, anxiety, and mental excitement, strain 
the blood vessels of the heart and brain, increase the rapidity of the 
heart, and thus over rill the vessels of the brain by the forcible action 
of the heart. 

Symptoms. — The symptoms may not appear for years after the 
occurrence of arteriosclerosis. This is the reason for making routine 
examinations of the patient. Dizziness and ringing in the ears are 
suggestive symptoms in persons of middle or advancing life. 

Frequency of passage of urine at night, shortness of breath on 
exertion, gas in the stomach, dyspepsia, constipation, cold hands and 
feet, and pain in the middle of the chest, sometimes occur. The 
symptoms are diverse and the diagnosis cannot be made without a 
thorough examination. The disease terminates in advanced cases 
in apoplexy, or in heart or kidney disease, in most instances. 

Treatment. — After anatomic change in the arteries has once oc- 
curred nothing can restore them to a normal condition. Treatment 
is directed toward preventing or limiting progress of arteriosclerosis, 
when it has arrived. Prevention means proper living. This means 
a reduction of the amount of food in those of overweight. Meat 
niav be taken onlv twice a week, in moderate amount, and fish twice, 



DEGENERATIVE CHANGES OF AGE 193 

a week. A milk, egg, vegetable and fruit diet, including all bread- 
stuffs and cereals, is the most useful. Alcohol should be avoided 
wholly in all its forms, with few exceptions. Smoking should be 
stopped, or curtailed to one mild cigar after dinner. It is well to 
drink not more than one cup of coffee daily, and that from which 
the caffein has been extracted. 

Not over three pints of liquid, including all kinds, should be 
taken in twenty-four hours. Overfilling the blood vessels with fluids 
increases the blood pressure and work of the heart. Sleep is im- 
portant, and may be encouraged by a warm bath (not hot) before 
retiring. For elderly persons who awaken early a daily nap is 
advisable. Cold baths are injurious in increasing blood pressure. 
Warm baths (100° to 105° F.) of five minutes' duration daily are 
most useful in relaxing blood vessels. The avoidance of cold climates 
and high altitudes is advisable, as both favor a high blood pressure. 
Chills should always be especially avoided by wearing woolen cloth- 
ing. Chills cause contraction of the superficial vessels and favor 
congestion of the kidneys. Regular daily exercise is of the greatest 
importance when the heart is not damaged too much. 

Waste matters in the blood are burned up in the tissues more 
readily by exercise. .'Golf, horseback riding, walking, and moderate 
outdoor work are most useful; heavy work and severe exercise, as 
tennis, are injurious. Fat, especially in the region of the belly, is 
harmful. The circulation in the vital organs is interfered with by fat, 
and also the movements of the heart, diaphragm and lungs. Special 
exercises, given under the supervision of a doctor, together with a 
suitable diet, will reduce abdominal fat. It is not at all essential 
to give up regular work; on the contrary, work is necessary for 
good health, and it is proverbial that many men begin to lose ground 
as soon as they retire from active work. Only work should be 
free from excitement, worry and anxiety. 

It is most important that the bowels move freely. Old age is 
favored by an accumulation of waste matters in the system. We have 
seen that absorption of poisons following the delay of intestinal 
contents is one of the recognized causes of arteriosclerosis. Diminish- 
ing the daily quantity of food favors constipation. To offset this 



494 DISEASES OF THE HEART AND BLOOD 

mix an equal bulk of bran and agar-agar, cut into one-half inch 
pieces ; a handful of the mixture should be taken each morning for 
breakfast. The mixture should be moistened with hot water, flavored 
with salt, and eaten with sugar, without any cooking. The bran 
is kept in packages by grocers, the agar-agar by druggists. The bran 
(Ealstons) is practically sterilized ordinary wheat bran, and acts by 
stimulating the bowels. The agar-agar is an Asiatic seaweed and 
swells in the digestive tract, but is not absorbed. It acts by supply- 
ing the bulk. The amount of salt taken by subjects of arteriosclerosis 
should be small. 

In a book such as this the chief object is teaching prevention of 
disease. The measures herein suggested should be applied before 
symptoms appear, and consist in proper living. "When symptoms 
occur one should seek the advice of his medical man. It is not possible 
to suggest any cure for symptoms of arteriosclerosis ; only a physician 
can do that as the result of a careful examination, by applying 
remedies to fit the particular case. 



PART III 

CHAPTER I 
VOMITING AND JAUNDICE 

Vomiting. Sea sickness. Car sickness. Vomiting of blood. Jaundice. 
Biliousness. 

VOMITING 

Vomiting is not a disease but a symptom of disease, and the 
causal disorders are numerous. 

Causes. — Acute indigestion (gastritis) is the most common and 
least serious cause of vomiting. This usually is produced by the 
eating of food which has begun to decompose and is laden with 
harmful germs. It is a form of food poisoning wrongly called 
ptomain poisoning. Milder forms of acute dyspepsia may be caused 
by eating indigestible food or too great quantities of food. In the 
vomiting of indigestion other symptoms are present, as pain or dis- 
comfort in the stomach or bowels, bad taste in the mouth, coated 
tongue and nausea, headache, depression of 'spirits, drowsiness, and 
diarrhea or constipation. Occasionally there may be some fever 
(101° F. to 102° F.) ; the attack lasts a few days. 

Vomiting with severe pain in the belly is often seen in acute 
appendicitis, gall-stones, stone in the kidney, strangulated rupture, 
and other conditions described elsewhere in this volume. 

Vomiting daily (with pain in the stomach, acidity, and gas) 
coming on regularly from one-half to three hours after eating, signi- 
fies ulcer of the stomach, especially when the pain is relieved by 
vomiting. Vomiting of blood indicates ulcer of the stomach if the 
symptoms of ulcer, just noted, have existed before the hemorrhage — 

495 



496 VOMITING AND JAUNDICE 

otherwise vomiting of blood from the stomach usually means some 
other trouble, as heart disease, etc. 

Vomiting, when the stomach is empty, speaks for some cause of 
irritation outside of the stomach, as from nervous disorders, poisoning 
by Bright's disease, or irritation in any part of the body. Morning 
vomiting is more frequently due to pregnancy, abuse of alcohol, 
tobacco smoker's catarrh of the throat, Bright's disease, and nervous 
disorders. 

Frequent attacks of vomiting of food, ten or more hours after 
it has been eaten, indicate spasm or obstruction of the outlet of the 
stomach. Chronic vomiting directly after eating may be due to 
spasm or obstruction in the gullet. Periodic attacks of vomiting 
with colic, distention of the bowels, and obstinate constipation 
strongly suggest chronic obstruction of the bowels. 

Vomiting following a one-sided headache, and without symptoms 
of indigestion, signifies a sick headache (migraine). In these cases 
there is a history of repeated attacks, and the disease is often in- 
herited. 

Vomiting is frequently seen in the beginning of acute diseases, 
as influenza, smallpox, scarlet fever, pneumonia, malaria, etc. ; but 
here the presence of fever, pain in the head and back, perhaps 
sore throat or eruption, will point to other cause than stomach 
trouble. 

Vomiting is quite frequently a disturbance of the brain. That 
produced by eye strain, by fatigue, emotion, fright, and severe pain 
is due to this cause. Also vomiting, accompanied by dizziness, noises 
in the ear, and deafness, may be classed under this head, as there is 
disorder of the nerve of hearing or its brain center. Vomiting and 
persistent headache are the most prominent symptoms in brain 
tumor, and also in meningitis with fever, stupor, delirium and 
unconsciousness. 

Vomiting is common as part of such nervous disorders as nervous 
prostration, hysteria, and the more serious locomotor ataxia. 

Vomiting is the most notable symptom after swallowing of most 
poisons, as is seen after overindulgence of alcohol. The poisons 
in the blood produced by disease are ordinary causes of vomiting, 



VOMITING 497 

as those of Bright's disease, diabetes, pregnancy, of sick headache, 
of oversecretion of the thyroid gland in goiter, and in periodic 
vomiting in children (cyclic vomiting). 

The swallowing of foreign bodies produces vomiting, which may 
not cease until after they are expelled from the bowels, as is some- 
times seen when children swallow coins. Tumor or inflammation of 
any of the abdominal organs will frequently cause vomiting. Severe 
cough of any kind may lead to vomiting, and it is seen frequently 
in whooping-cough and in consumption. Both sea sickness and car 
sickness are well-known forms of vomiting. 

General Treatment of Vomiting". — The patient should wash out 
his stomach by swallowing a pint or two of hot water and, after 
vomiting it, repeat the process several times. Also a quart or two 
of warm soapsuds should be injected into the bowel to move the 
bowels satisfactorily. Most cathartics will be vomited but an adult 
may swallow two or three compound cathartic pills, and a baby or 
child may be given a tablet of one or two grains of calomel to 
advantage. The patient should rest quietly on his side in bed, and a 
mild mustard paper may be placed over the stomach. 

Eo food should be taken for twelve to twenty-four hours, or 
until the nausea and vomiting cease. A tablespoonful of cracked 
ice with a few drops of brandy may be taken occasionally, or — if 
more agreeable — hot water may be sipped to relieve the thirst. When 
vomiting stops the patient may take a tablespoonful every two 
hours of one of the following : milk and lime water, or milk and ice 
cold Apollinaris water, equal parts; clam juice; beef juice squeezed 
from a lightly broiled steak; or white of egg, stirred into one-half 
cup of cold water and flavored with a few drops of lemon juice. 
After a few hours the amounts may be increased if the patient 
retains the food satisfactorily. ■ 

In persistent vomiting, tablespoonful doses of iced, dry cham- 
pagne will sometimes be borne better than any other nourishment. 
Among drugs, the tasteless, white powders, bismuth subnitrate, in 
one-third teaspoonful doses, with cerium oxalate in five grain doses, 
are most successful in relieving vomiting. They should be dropped 
dry on the tongue in the above doses every four hours. The diet 



498 VOMITING AND JAUNDICE 

may be extended to cereals, toast, soft egg, etc.. as improvement 
takes place. 

SEA SICKNESS AND OAR SICKNESS 

Persons about to take a sea voyage should abstain from unneces- 
sary fatigue in shopping, packing, farewell festivities and dinners, 
so as to keep in good condition, and take fifteen grains of sodium 
bromid with one-tenth grain of ipecac in a glass of water after meals, 
three times daily during the two days before and after sailing. There 
should be a free movement of the bowels each morning during this 
time, for which purpose a glass of citrate of magnesia or other 
aperient water should be taken. When on shipboard the voyager 
should lie down, warmly covered, on deck. or. if having an airy 
stateroom, go to bed, and avoid smells, sounds or moving objects — 
as the water or movements of the vessel. The eyes may be kept closed 
with this in view. 

Iced, dry champagne, or two tablespoonfuls of brandy in a glass 
of cracked ice, may be taken in tablespoonful doses at half hour 
intervals to relieve vomiting, should it occur. A hot water bag at 
the feet and mustard plaster over the stomach are also serviceable in 
severe attacks, in which it may be necessary to have hypodermics 
of morphin and atropin administered by a doctor. A dose of eight 
grains of veronal may be beneficial. For the treatment of vomiting 
in pregnancy and alcoholism, see special articles on these subjects. 

VOMITING OF BLOOD 

Blood from the stomach is usually dark or brownish, owing to 
the action of the acid in the gastric juice upon it ; but occasionally 
it is quite red. It is usually accompanied by retching and vomiting 
and may be mixed with food. There may be difiiculty in distinguish- 
ing blood from the nose or throat, which has been swallowed, from 
that arising from bleeding of the stomach. Blood will usually be 
seen about the nose in nosebleed, and in bleeding from the stomach 
there will usually be a previous history of pain in the stomach and 
indigestion. Or in bleeding from the stomach there may be disease 
of the heart, spleen, liver, or fever, which sometimes produce such 
a result. 



VOMITING 499 

Bleeding from the stomach must also be discriminated from 
hemorrhage from the lung which is usually (but not always) brought 
on by coughing, or causes coughing, and the blood is bright red, alka- 
line, often frothy, and accompanied perhaps by known disease of the 
lungs or heart. Fainting is common after vomiting of a large amount 
of blood in ulcer, but death occurs in but one case out of ten 
in ulcer of the stomach (Lockwood). 

Treatment. — The patient should be put to bed, with the foot of 
the bed raised a foot or so, and an ice-bag kept continuously over 
the stomach. The patient should not be permitted to talk, and all 
food or drink by the mouth should be withheld. The best remedy, 
if it can be obtained, is adrenalin solution (1 to 1,000) given in 
five drop doses each half hour in a little cracked ice and water. 

Of course a physician should be summoned as soon as possible. 
A quart of warm water, containing a heaping teaspoonful of salt, 
may be injected very slowly into the bowel from a fountain syringe 
hung some four inches above the patient, so that it will be absorbed 
and retained. 

For three to five days after the bleeding has ceased no food 
or water should be given by the mouth. The mouth may be washed 
frequently with listerine or saturated solution of boric acid (as 
much as will dissolve in cold water) and, if there is much thirst, 
a solution of baking soda (one level teaspoonful to the quart of 
water) may be allowed to flow slowly into the bowel once or twice 
daily, so as to be retained. On the fourth day the patient may have 
peptonized milk, and water containing five grains of baking soda — 
of each four teaspoonfuls, giving first one and then the other hourly 
(See Ulcer). 

In severe hemorrhages from the stomach the physician will advise 
the injection of blood from another healthy individual into the 
blood vessel of the patient as the most life-saving treatment. 

Causes. — Vomiting of blood is a symptom of many conditions, 
as has been suggested. Coming on in young women, or in patients 
who have suffered from pain at regular times after eating, with 
acidity and perhaps gas, it is apt to be due to ulcer. Cancer of the 
stomach is a frequent cause in persons of middle age or past but 



500 VOMITING AND JAUNDICE 

the bleeding is not apt to be profuse. Blows, kicks, and injuries 
to the belly wall may cause hemorrhage from the stomach. Swallow- 
ing of blood from nosebleed, especially if occurring during sleep, 
may lead to vomiting of blood in the morning. After operations, 
as for adenoids or extraction of teeth, vomiting of blood is common 
but would not be apt to cause doubt as to the source. 

Disease of the heart, liver, spleen, scurvy, yellow fever, small- 
pox, measles, severe anemias, influenza, dengue, purpura, chronic 
appendicitis and gall-bladder trouble, occasionally produce vomiting 
of blood. In women it rarely appears in place of normal menstru- 
ation. Finally it sometimes is seen in persons without any apparent 
cause and in whom it never recurs. Taking cases due to all causes, 
patients rarely die while vomiting blood or directly from it. 



JAUNDICE 

Causes. — There are many causes of jaundice, but the commonest 
form described here is due to an attack of acute indigestion or catarrh 
of the stomach and first pan of the bowel. 

As a result of this catarrhal inflammation, the lining mucous 
membrane of the intestine becomes swollen, and in this way obstructs 
the opening of the tube (common bile duct) which conveys bile from 
the liver into the bowels. The opening of this bile duct in the intes- 
tine is about three or four inches below the point where the stomach 
ends and the bowel begins Fig. -"7. E . Not only is the bile duct 
closed by swelling of the mucous membrane about its aperture in the 
bowel, but this opening is often plugged with mucus which is being 
secreted from the inflamed area. Jaundice is the direct result of this 
plugging and obstruction of the bile duct. Since the bile is prevented 
from flowing into the bowel, as it naturally should, it backs up into 
the ducts of the liver until it is reabsorbed into the blood. The 
result of this is that the skin and whites of the eyes are tinged 
from pale yellow to olive or greenish-black, and the urine dark 
brown, while the bowel discharges, being deprived of bile, become 
liaht colored or almost white. 



JAUNDICE 



501 



Simple catarrhal jaundice occurs more often in the young pre- 
viously healthy persons, and usually follows an attack of acute indi- 
gestion ; but it may be 
caused by exposure to 
the cold, or fright, and 
it may accompany ma- 
laria and other dis- 
eases. It is sometimes 
seen as an epidemic in 
spring and fall. 

Symptoms. — The 
jaundice, or yellow ap- 
pearance, sometimes 
comes on without any 
previous warning or 
discomfort, but gener- 
ally such symptoms as 
the following may ap- 
pear several days, rare- 
ly a week or two be- 
fore the jaundice is 
noticed. There is loss 
of appetite, nausea, a 
feeling of heaviness 
and distress in the re- 
gion of the stomach 
some hours after eat- 
ing, and perhaps dis- 
comfort in the right 
side; there is a bad 
taste, and the tongue 
is coated. In severe 
cases there are head- 
ache, pains in the back 
and limbs, and fever, the temperature rarely rising over 102° F. at 
the onset. The pulse, however, is usually slower than normal. 




Fig. 57. — Position of Gall-bladder and Appendix. 
R R Lower border of ribs. S Beginning of small 
intestine (duodenum) at outlet of stomach. Seat of 
duodenal ulcer in first inch of duodenum which ends 
at E. gb Gall-bladder under border of ribs, right 
side. B Site of entrance of common bile duct in 
duodenum which is formed by duct from liver (L) 
uniting with duct from gall-bladder and duct from 
pancreas, a large gland at P. 

H H Bony prominences at forward and upper part of 
hip bone. N Navel. Midway in an imaginary line 
drawn from the navel to H on the right side is the 
point of tenderness on deep pressure in appendicitis 
at X. A Appendix. This begins in reality about 
2 inches below the point of tenderness and pain in 
appendicitis and hangs down still lower in the 
abdomen. L I Large intestine beginning at S I, 
where the small intestines terminate in the large. 



502 VOMITING AND JAUNDICE 

Diagnosis.— The appearance of jaundice following an attack of 
indigestion in young healthy persons without the occurrence of 
severe pain, is strongly indicative of catarrhal jaundice, just 
described. The graver forms of jaundice are more apt to he present 
in middle or advanced age and include more frequently jaundice 
due to obstruction produced by two diseases — gall-stones and cancer. 

Jaundice from gall-stones is three times more common in women 
than in men. When there is a history of sudden and severe attacks 
of pain in the region of the stomach, occurring before the appear- 
ance of jaundice, one may be reasonably sure of the presence of 
gall-stones. Jaundice produced by cancer is usually the result of 
prolonged irritation of the gall-bladder and bile ducts by gall-stones. 
Attacks of severe pain may precede and accompany the jaundice 
of cancer in persons of middle age or past middle age. Persistent 
jaundice and emaciation are characteristic of cancer of the gall- 
bladder and liver. 

There is another form of jaundice, not uncommon in newborn 
children, which appears about the third or fourth day of life and 
lasts for about a week or so, and is characterized by some loss of 
weight, general yellowness, and the passage of dark-colored urine. 
This is a harmless condition and needs no treatment. There is, 
however, a rare form of jaundice in the newborn which is accom- 
panied by great emaciation and is often fatal, being due to changes 
in the structure of the liver. The doctor must be called in to 
establish the difference here. 

Catarrhal jaundice lasts two weeks in mild cases, four and even 
twelve weeks in the more severe. If it persists beyond this time 
it is apt to be not of the catarrhal form, but of some more serious 
variety indicative of liver disease. 

Treatment. — If there is any fever (the temperature above 99° 
F.) or much weakness and general discomfort, the patient should 
go to bed; otherwise he may safely keep about. But the requisite 
diet is not conducive to work. This should consist at first of skim 
milk, meat broths free of fat, or white of egg beaten up with 
about six times its bulk of cold water, and given when the froth 
subsides, flavored with a few drops of lemon juice. Some such 



BILIOUSNESS 503 

nourishment should be given every two hours of the day, with 
occasionally milk toast, crackers, or a bland cereal like wheat-flour or 
cornstarch gruel. 

The bowels should be moved freely every day with a tablespoonful 
of Epsom salts dissolved in as little water as possible, and followed 
immediately by a whole tumblerful of pure water. Instead of Epsom 
salts, the daily use of Seidlitz powders, citrate of magnesia, Hathorn 
water, Hunyadi Janos, or Carlsbad salts, may be more agreeable; 
the cathartic should always be taken early in the morning before 
eating. 

As the feeling of discomfort from the indigestion disappears 
and the passages from the bowels regain a natural color, the diet 
may be extended to lean meat, chicken, fish, cooked vegetables, such 
as mashed or baked potatoes, peas, string beans and spinach, and 
cooked fruits. Much water should be taken throughout the disease, 
particularly Apollinaris or soda water, if possible. 

Daily injections of a pint of cold water into the bowel, to be 
retained as long as possible, are useful. Itching is relieved by 
bathing the skin with tepid water containing a teaspoonful of baking 
soda, or half a teaspoonful of carbolic acid in half a pint of alcohol 
and hot water, or in a pint of hot water alone. 



BILIOUSNESS 

Causes. — This is a vague term describing, not an exact condition 
of the body, but, in an indefinite way, a group of symptoms. It is 
probable that there is some acute indigestion or more or less catarrh 
of the stomach and first part of the bowel, in many cases, and that 
poisons, developed by the decomposed food in the stomach and bowels, 
are absorbed into the liver, and derange that organ so that symp- 
toms of indigestion and liver disturbances result. Persons having 
gall-stones, or inheriting gouty tendencies, are frequently subject to 
biliousness. 

Symptoms. — There is loss of appetite, languor, headache, or 
dizziness, and depression of spirits. The tongue is coated with often 



504 VOMITING AND JAUNDICE 

a yellowish hue in the center, and there may be a bitter taste. Con- 
stipation is the rule. The whites of the eyes are apt to become 
slightly yellow, and the skin sallow. Sometimes after several days 
of such symptoms, a violent headache comes on with nausea and 
vomiting followed by relief. 

Biliousness is more frequent in autumn and spring. It arises 
in some persons from eating special articles of food, as eggs, milk, 
and coffee. Probably the fat in these substances disturbs digestion. 
In most cases of biliousness we see neither the marked symptoms of 
bile absorption, as the white bowel discharges and pronounced yellow- 
ness of jaundice, nor the characteristic signs of acute indigestion 
with the tenderness of the stomach and vomiting, but the condition is 
like a mild admixture of both these disorders. 

Treatment. — The avoidance of certain articles of diet may secure 
freedom from the trouble. Measures calculated to overcome con- 
stipation are useful, such as exercise, especially horseback riding, 
performing movements for fifteen minutes each morning, in which 
the body at first erect, with the hands held directly overhead, is bent 
from the hips forward until the finger tips touch the floor, and the 
body swayed at the hips from side to side (except in gall-stones). 
Rowing and bicycling are excellent; also massage of the abdomen. 
An occasional dose of calomel, not oftener than once a week when 
the symptoms are felt to be approaching, is useful: two or three 
grains should be taken followed in six hours by a Seidlitz powder 
or a tablespoonful of Epsom salts in a glass of water. 



CHAPTER II 
CHRONIC STOMACH TKOUBLES 

Gall-bladder disease. Ulcer of the stomach and duodenum. Cancer of the 
stomach. Chronic appendicitis. Enteroptosis. Atony. Nervous indi- 
gestion. 

We have used the term "stomach trouble" advisedly because its 
very indefmiteness enables us to establish a variety of diseases which 
are commonly called stomach trouble by the patient. It is extremely 
important to separate the functional from the organic diseases — 
that is, to know when we are dealing with the disturbance of the 
normal functions of the digestion, and when there is actual structural 
alteration of the organs of digestion. 

When pain is real and severe, the disease is apt to be organic 
whether the pain be of a griping, boring, cutting, cramplike, burning 
or gnawing character. In functional diseases the complaint is more 
often of a feeling of weight, pressure, fullness, heaviness or discom- 
fort in the belly, and nausea. 

The discomfort caused by functional disease is not usually severe 
enough to keep the patient awake at night. In many organic diseases 
of the digestive organs the pain is felt only at certain periods with 
intervals of weeks, months, or even years of good health. In func- 
tional disease the discomfort is more apt to be more or less constant. 
Of course no hard and fast rules are possible and there may be 
exceptions to those just given. Then again the subjects of that form 
of faulty development, known as enteroptosis, are more prone to 
have functional than organic disease of the digestive apparatus. 

We may classify all so-called stomach troubles as follows : One- 
third are caused bv faulty development, or enteroptosis. This group 

505 



506 CHRONIC STOMACH TROUBLES 

includes atony and nervous disorders of the stomach, because, as 
will be seen in the following pages, these three conditions are asso- 
ciated. Another third of chronic stomach troubles is due to general 
diseases, as consumption, Bright's disease, anemia, and various other 
disorders. Of the remaining thirty-three per cent, of chronic stomach 
troubles only one-third, or ten per cent, of all chronic stomach 
troubles, consists in organic disease of the stomach itself — which 
includes ulcer and cancer of the stomach. The final twenty per 
cent, of all stomach troubles are produced by disease of the gall- 
bladder, appendix, duodenum (ulcer of), and of other organs in 
the belly outside of the stomach. Disturbance of the nervous 
connections of these organs with the stomach leads to disorder of 
the stomach itself, and this becomes most apparent to the patient. 
Finally, we emphasize the fact that only about ten per cent, of all 
chronic troubles are actual diseases of the stomach itself (ulcer and 
cancer), while ninety per cent, are disturbances of the stomach due 
to diseases of other organs. 

GALL-BLADDER DISEASE 

This is very common and occurs three times as often in women 
as in men, and usually in middle life. Gall-bladder disease means 
commonly an inflammation of the gall-bladder with or without the 
presence of gall-stones in the gall-bladder. Gall-bladder trouble 
most frequently is caused by typhoid fever or appendicitis, either 
of these having occurred years before. 

The gall-bladder is of much the size and shape of a large pear 
with the big end below and resting under and a little beneath the 
lower rib on the right side of the abdomen, and directly below 
the nipple of the right breast (Fig. 57 gb). Gall-bladder disease 
is almost always called stomach trouble by the patient and often by 
the doctor as well. 

Symptoms. — It often begins with sudden attacks of gas and 
upward pressure in the stomach, coming on at irregular times after 
food and relieved by constant belching of gas and by the spitting 
or vomiting of food. There may be intense burning in the throat 
from acid brought up. 






GALL-BLADDER DISEASE 507 

This lasts but a short time and passes away gradually, without 
treatment, the patient remaining perfectly well between the attacks, 
which may be weeks or months apart. Occasionally bilious attacks, 
with vomiting of bile, may be the first sign of gall-bladder trouble. 

The well-marked attacks of gall-stone colic are those beginning 
with sudden and violent pain in the stomach, the pain being also 
felt to the right of the stomach under the ribs, and in the right 
shoulder blade. There are frequent belching of gas, nausea, and 
vomiting and, after some time, the terrific pain passes away as 
suddenly as it came, without any treatment. 

These attacks come on at irregular times day or night, without 
any relation to meals, and they begin and end suddenly without 
any apparent reason for either onset or end. The eating of a very 
large meal may precipitate an attack, however. The attacks may 
be months or years apart, and in the interval the patient may be 
perfectly well. 

Another form of gall-bladder disease is shown by persistent dull 
pain which is felt both in the stomach and over the lower part of 
the right side of the chest in front. This pain is increased by eating, 
exercise, or deep breathing. This form is often mistaken for pleurisy. 
Such attacks may last for days or weeks, and in the intervals the 
patient may feel in partial or perfect health. 

Jaundice after an attack of abdominal pain is almost certain 
evidence of gall-stones — but is often absent. The shortness of the 
attacks in most cases of gall-bladder disease, and the compara- 
tive health between the attacks, serve to separate gall-bladder trou- 
ble from true disease of the stomach. Sometimes, however, there 
may be fairly continuous pain in the stomach with gas and food 
coming up into the mouth. The real test in these cases is pres- 
sure of the finger tips hooked up under the ribs on the right side, 
directly under the nipple, while the patient takes a long breath. 
Marked tenderness here, as compared with that on the other side of 
the belly, in the same relative position, is a pretty sure sign of gall- 
bladder inflammation. 

Treatment. — If gall-bladder disease or gall-stones are neglected, 
serious consequences may follow, but there is usually no immediate 



508 CHRONIC STOMACH TROUBLES 

necessity for operation as in the case of appendicitis. In fact in 
acute inflammation of the gall-bladder and in complete obstruction 
of the main bile duct for stone, it is often better to postpone surgical 
operation until the acute trouble subsides. 

The chief dangers likely to follow gall-bladder disease include 
abscess, perforation and gangrene of the gall-bladder (these com- 
plications are rare but demand instant operation), general inflam- 
mation of the bile passages throughout the liver (cholangitis), and 
obstruction to the flow of bile from the liver to the bowels owing 
to the presence of a gall-stone in the common bile duct. The exist- 
ence of chronic inflammation of the gall-bladder (with or without 
stones) for years may result in degeneration of the heart or kidneys, 
or both, from the constant entrance of germs (living in the gall-blad- 
der) and their poisons into the blood and their dissemination to 
these organs. Constant irritation of the gall-bladder by gall-stones 
may lead to cancer of the gall-bladder, and permanent damage to the 
heart, kidneys, "rheumatism/'' of joints, and severe headaches, are 
common results of long-standing gall-bladder infection. 

The treatment of gall-bladder disease, whether gall-stones are 
present or not, is essentially surgical. In acute inflammation of the 
gall-bladder, a complication of typhoid fever and other infections, 
only medical treatment is usually advised. 

The writer is aware that many leading medical men preach 
the harmlessness of gall-stones, when they are not producing pain, 
but he believes the surgeon who actually sees the various conditions 
caused by gall-bladder disease, is much better fitted to judge of the 
necessity of surgical operation. Even the most skilled medical men 
must guess as to the exact condition of any patient with gall- 
bladder disease, whereas the surgeon knows, in the case he operates 
upon. The opinion of the man who constantly knows is better 
than the man who constantly guesses. When the physician is able 
to follow his patient to the operating room he will hold the same 
views as does the surgeon. 

Leading surgeons do not believe that gall-stones are harmless. 
even though patients harbor them for years, and die of other diseases. 
They are a greater menace to life than an operation by a competent 



GALL-BLADDER DISEASE 509 

surgeon. No medicine will dissolve or remove gall-stones from 
the body — they can only be surely removed by the surgeon. It is 
true that they sometimes escape into the bowels, and thus from the 
body; but commonly many more remain and, if symptoms still 
occur, it is because of the gall-stones remaining or the inflammation, 
which they have caused, persisting. Chronic inflammation of the 
gall-bladder, with or without stones, is best treated surgically — in 
most cases by removal of the gall-bladder. 

The operation of removing gall-stones without removing the gall- 
bladder has fallen in disrepute because the trouble, in most cases, 
returns within a few years. The gall-bladder — like the appendix — 
is a useless organ and may be removed without interfering with the 
flow of bile from the liver into the bowels (See Fig. 57 gb). 

The danger from operations on the gall-bladder and bile ducts is 
slight in the hands of skillful surgeons. In simple cases of gall- 
stones the mortality is less than one in two hundred operations, and 
in operations involving the more complicated diseases of the gall- 
bladder and bile ducts the danger is not great. In four thousand 
operations of all kinds on the gall-bladder and bile passages including 
those of cancer, performed by the Mayo brothers prior to 1911, the 
mortality was 2.75 per cent. 

In the attacks of violent pain caused by gall-stones, nothing is 
so effective as morphin * given by syringe under the skin, by a physi- 
cian. From one-quarter to one-half a grain of morphin is necessary 
to give relief. The application of flannel cloths to the region of 
the stomach, wrung out in turpentine and then in hot water, is of 
value. Three thicknesses of flannel about one foot square, and 
covered with rubber cloth, or oil silk and a hot water bag, are 
desirable. 

In case a doctor cannot be secured, and the attendant is unfit 
to give morphin under the skin, one may give an adult patient with 
the agonizing pain of gall-stone colic a teaspoonful of paregoric 1 
every fifteen minutes for three or four doses, or a single dose of ten 
drops of laudanum, 1 or one-quarter grain of morphin * in water. 

1 Opium (including moTphin, paregoric and laudanum) is a powerful drug 
and is only sold on a doctor 's prescription. 



510 CHRONIC STOMACH TROUBLES 

These amounts should not be repeated without a doctor's advice. But 
these may cause vomiting, and the action of these medicines is very 
slow and unsatisfactory compared to giving morphin under the skin. 

No cathartic, food, or drink should be given patients for twenty- 
four hours after an acute attack. After this time an enema should 
be given and tea and toast allowed. 

The medical treatment of gall-bladder disease, with or without 
gall-stones, tends to lessen inflammation of the gall-bladder. Indeed, 
the pain produced by gall-stones is either caused by the inflamma- 
tion of the gall-bladder they set up or by the gall-stones entering 
the bile ducts where the spasm provokes great pain. The exponents 
of medical treatment believe that if the inflammation of the gall- 
bladder and ducts can be relieved, the gall-stones may remain with- 
out danger to the patient. But the constant presence of gall-stones is 
always a menace to life and health, and medical treatment in inflam- 
mation of the gall-bladder is usually a failure. 

The best treatment consists in the taking of a teaspoonful, or 
less, of artificial Carlsbad salts in a whole glass of hot water one- 
half hour before breakfast and an hour before dinner. If the 
cathartic action is too great the amount of salts should be dimin- 
ished. Greasy and acid food, as acid fruits and vegetables, should 
be avoided, and no severe exercise should be taken for a year after a 
severe attack of gall-stone colic. A daily enema, containing a tea- 
spoonful of salt in a quart of water, and taken so slowly that it be 
retained, is useful when there is jaundice. The itching caused by 
jaundice is relieved by warm baths and powdered starch on the 
skin. 

CHRONIC ULCER OF THE STOMACH AND FIRST PART OF THE BOWEL 

(Duodenum) 

This disease in most cases involves the outlet of the stomach 
or first three-quarters of an inch of the beginning of the bowel (duo- 
denum, Fig. 57, S). There is usually a round, raw area ranging from 
the size of the end of a lead pencil to that of a nickel. If the ulcer- 
ated spot is larger than one-quarter of a dollar it is usually a cancer. 



CHRONIC ULCER OF STOMACH 511 

An ulcer is a crater, and as clearly defined as though someone 
had punched out a portion of the stomach or bowel wall without 
quite going through the whole thickness. The ulcer may in time, 
however, eat entirely through the wall into the abdominal cavity 
(perforation). 

The disease often begins in youth, and exists for years before 
it is clearly recognized. At one of our largest clinics it has been 
found that patients have been sufferers with ulcer for about ten 
years before they present themselves for surgery. It is more com- 
monly seen in the middle aged and, unlike gall-bladder disease, it is 
three times more common in men than in women. 

Symptoms. — Symptoms begin with a feeling of weight and full- 
ness in the stomach and belching of sour matter one-half to three 
hours after meals. The attacks last weeks or months, and are 
followed by periods of weeks, months, or even years in which the 
patient feels perfectly well. He is more apt to be well in summer 
and attacks are more common in spring and fall, or following the 
wetting of the feet, or getting tired or worried, or after an indigestible 
meal. 

The more characteristic symptoms are : At first after the heart- 
iest meal, and later one-half to four hours after every meal, 
there is a colicky, gnawing, boring, or burning pain, with disten- 
tion, and a hungry, sour feeling in the stomach; this has been 
called "hunger pain" because it is associated with hunger and is 
relieved by eating, drinking, by alkalis (as baking soda or saleratus), 
and by vomiting. There is usually much eructation of gas and 
often bitter or acid fluid comes up into the throat and mouth and 
causes burning in the mouth and chest. The pain is commonly 
most severe in the middle of the night and the patient will often go 
to bed with a cracker, cookie, or glass of milk by the bed to relieve 
his suffering. The constant acidity of the mouth may corrode the 
teeth. Vomiting may or may not be frequent. Often the subject 
forces his finger down his throat to bring on vomiting and thus 
secure relief. 

The most essential features are the regularity with which the 
pain occurs — from one-half to four hours after eating — and the 



512 CHRONIC STOMACH TROUBLES 

relief obtained by drinking much fluid to dilute the acid, or by 
taking soda or magnesia to neutralize the acid, or by getting rid 
of the acid through vomiting. When the pain is severe there 
may be tenderness over the pit of the stomach, or more often, 
somewhat to the right of this point. Vomiting of blood or its 
passage from the bowels occurs in about one-third of the cases of 
ulcer. 

If the patient has previously suffered from the symptoms just 
described the loss of blood from stomach or bowels is positive proof 
of ulcer. When these preliminary symptoms are wanting the diag- 
nosis of ulcer is improbable even with such hemorrhages. When 
blood is passed from the bowels it is usually of a dark, tarry appear- 
ance. There is generally a very considerable loss of weight after 
one of these hemorrhages. 

The attacks caused by ulcer grow worse in time, and the periods 
of relief less marked, so that distress becomes continuous and the 
pain is not relieved by food, alkalis and vomiting, as in the early 
years. 

Cause. — The cause of ulcer is not surely known, but ulcer is fre- 
quently associated with chronic appendicitis and sometimes with gall- 
bladder disease. It may be caused by chronic tonsillitis or Riggs' 
disease. It has only recently been recognized as a common cause of 
digestion in men, and cases have heretofore been regarded as "ner- 
vous dyspepsia" or "acidity." Chronic ulcer of the stomach and bowel 
is nearly as common as appendicitis, and has been found in one per 
cent, of all persons dying from all causes. 

Diagnosis. — While the relation of pain to the taking of food is 
the most distinguishing feature in ulcer, no such relationship exists 
in gall-bladder disease. 

The appetite is generally good in ulcer. The dangers of ulcer, 
when left to run its course, are perforation of the stomach and 
bowels, followed by immediate peritonitis or inflammation of the 
bowels, and bleeding from the bowels or vomiting of blood. The 
latter is rarely fatal. The gradual closing of the outlet of the stomach 
(pylorus) by contraction of the ulcer is also a symptom. This leads 
to vomiting of food and consequent starvation. 



CHRONIC ULCER OF STOMACH 513 

Ulcer of the stomach not infrequently results in cancer and this 
is the greatest danger of all. The larger number of cases of cancer 
of the stomach (60 to 70 per cent.) originate in ulcer, and cancer 
of the stomach is the most common form of cancer. Ulcer in the 
first part of the bowel (duodenum) practically never terminates in 
cancer, however. When pain does not occur until three or four hours 
after eating the ulcer is more apt to be in the bowel than in the 
stomach. In ulcer of the stomach the pain is likely to be felt much 
sooner after meals. 

The history of the symptoms from the beginning will often enable 
a doctor to make a positive diagnosis — it is better than any method 
of examination. The author knows of a patient who had trav- 
eled through Europe from South America to obtain a diagnosis 
in a case of chronic stomach trouble, finally to have it made by a 
nurse who was taking notes for a physician at a celebrated clinic 
(Mayo) in this country. She had been taught that such a his- 
tory as we have described means a probable case of ulcer. The 
diagnosis was proved correct at operation. The patient was quite 
indignant that a nurse should have the impudence to suggest a 
diagnosis when great authorities had failed. 

Physical examination may be of no value or may show tender- 
ness over the site of the ulcer; the finding of blood and a large 
amount of acid in the stomach contents, and blood in the bowel 
discharges, favors the diagnosis of ulcer, and the x-ray may actually 
show its presence. 

Treatment. — Here again medical opinion is divided between med- 
ical and surgical treatment. After a surgeon has had numbers of 
patients, who have been "cured" three or four times, come to him 
with an ulcer visible across the room at operation, he naturally be- 
comes skeptical concerning the results of medical treatment. How- 
ever, since the disease must exist some time before one can make a 
positive diagnosis of chronic ulcer, and since many patients are per- 
manently cured by medical treatment, this should be pursued in the 
first few attacks at least. Of course such treatment must be prop- 
erly directed by a physician. The percentage of cures of chronic 
ulcer by medical treatment is doubtful since recurrence may arise 



514 CHEOXIC STOMACH TROUBLES 

years after apparent cure. Xo case should be considered cured 
until at least two years have elapsed after apparent recovery. 

It is stated by good authorities that 40 per cent, of cases are 
permanently cured by medical treatment. The medical treatment 
consists of rest in bed, heat to the abdomen, and — after a few days 
of starvation — the use of a diet of milk and raw eggs, with alkalis 
and bismuth to reduce acid in the stomach. During the periods 
when the patient feels perfectly well the ulcer may be wholly 
unhealed, as may be shown at operation. 

The surgical treatment consists in removal of the ulcer-bearing 
area, when possible, and usually in making a new outlet in the 
lowest part of the stomach, and connecting this with an opening in 
the first part of the small intestine (gastrojejunostomy). The food 
is then prevented from leaving the stomach by the normal outlet, 
through closure of this outlet. The operation in the hands of 
experts is but little more dangerous than that for chronic appendi- 
citis. Experts, like the Mayo brothers, lose but one or two patients in 
every two hundred operations for ulcer. The results of the operation 
are very favorable — providing expert surgeons are employed. 

At the Mayo clinic in 600 cases of ulcer it was found, two years 
after operation, that 67 per cent, were completely cured and 96 per 
cent, were benefited. In some 1,341 cases of ulcer operated upon, the 
Mayo brothers found a large per cent, had, at the same time, chronic 
appendicitis and gall-bladder trouble which needed operation for 
cure. This is another reason for operation, as it may be impossible 
to diagnose such complications, and they cannot be cured by medical 
treatment. 

CANCER OF THE STOMACH 

Cancer of the stomach is the most common of all cancers, con- 
stituting about one-third of cancers in all parts of the body. 

Treatment. — Cancer of the stomach is curable in its early stages 
by surgery, and by no other means; also it is only in the early 
stages that it is curable. For this reason the disease is mentioned 
in this book — to call the layman's attention to the earliest symptoms 
suggesting cancer, so that he may at once consult a physician. 



CANCER OF THE STOMACH 515 

Symptoms. — Cancer occurs more often between the ages of forty 
and sixty, more frequently in men. If it affects the body of the 
stomach and not the inlet or outlet, the symptoms are so slight in 
many cases as not to be noticeable until the disease has spread to 
other organs. Cancer of the outlet is the rule and in these cases 
there is obstruction and vomiting. 

Indigestion beginning for the first time in the middle-aged, and 
accompanied by loss of weight, strength, and appetite, should cause 
the patient to lose no time in seeking a good diagnostician. In 
other cases the patient has suffered at various periods for years, 
from dyspepsia and pain, as described under ulcer, and the condition 
has become constant, instead of only at certain periods. The pain 
becomes more continuous, and is not relieved by food; vomiting is 
more frequent; appetite is lost; and meat and fat are particularly 
repugnant (this applies to most cases of stomach cancer). Weight 
and strength begin to fail. It is probable that 70 per cent, of cases 
of cancer follow ulcer, and that many have a past history of indiges- 
tion — sometimes years before, how r ever. In many cases of ulcer 
there is no pain, so that the disease is not recognized until cancer or 
other complication occurs. 

The pain in cancer is dull and sickening, and usually made 
worse by eating. The matter vomited is peculiar, as it represents 
food poorly digested which has been taken hours or days before. 
The stomach contents often has a foul odor and may be of the 
color of coffee grounds and may contain blood. The patient usually 
looks calm and hopeless, and the face is pinched, pale, or of a lemon 
color. In addition a small lump or tumor may be felt by the patient ; 
it is movable and is felt above and often a little to the right of the 
navel. 

Two signs are sought by the doctor: the presence of tumor over 
the stomach region, and the presence of obstruction at the outlet 
of the stomach. The existence of either of these is a probable sign 
of cancer. If a handful of raisins and partly cooked rice are eaten 
the night before with the supper, and the stomach emptied before 
eating in the morning by the stomach tube, in most cases, the pres- 
ence of the raisins and rice in the stomach contents — especially with 



516 CHRONIC STOMACH TROUBLES 

other food — indicates the existence of obstruction to the outlet of the 
stomach. 

X-ray examination is worth all the other means of diagnosis in 
stomach troubles together. In suspected cancer it may be of the 
greatest value. 

Outlook.- — To summarize, it may be said that the middle-aged 
man should seek the earliest medical advice when attacked by con- 
stant stomach trouble, and that he who has had stomach trouble in 
past times, like that described under ulcer, is also apt to have 
cancer later — this should be kept in mind. In some cases the ex- 
istence of cancer is doubtful, and patients should not hesitate to allow 
a skillful surgeon to open the abdomen in order to explore. Delay is 
fatal. 

The Mayos had operated on 627 cases of stomach cancer up to 
1910. Some of these were too far gone to remove the cancer. They 
have reported that 20 per cent, of the cases, in which the cancerous 
part of the stomach was removed, were alive and well three years 
after operation. 

About nine patients in one hundred die from the operation 
(Mayo). Without operation cancer of the stomach is invariably 
fatal, usually in one and one-half to two years. 

In a large percentage of the cases operated upon, relief is only 
obtained by making a new outlet to the stomach to allow of escape 
of the stomach contents. In these cases the cancer is too far advanced 
to permit of its removal. Part of the stomach may be removed with 
immunity but not the larger part. Cancer always begins as a local 
disease and, so far as is known, only local means will cure it. The 
whole success of surgical removal of cancer anywhere depends upon 
its early removal. 

STOMACH TROUBLE FROM CHRONIC APPENDICITIS 

Many cases of chronic appendicitis present no local symptoms of 
trouble with the appendix — that is, there is no pain or tenderness 
over the appendix, the latter situated at a point two inches or so 
below a point three or four inches to the right of the navel and on 
a horizontal line with it. In other words the appendix is situated 



FUNCTIONAL INDIGESTION 517 

in the abdomen nnder a point on the belly wall below and to the 
right of the navel (Fig. 57, N). 

Pressure on the belly below and to the right of the navel will 
give pain in acute appendicitis. 

Symptoms. — In the stomach trouble caused by chronic appendi- 
citis the pain occurs in attacks or at periods, with slight discomfort, 
or none, between these attacks. The pain is in the stomach region 
above the navel, but with a tendency to extend down toward the 
navel or below. 

Diagnosis. — The pain is not severe and is not relieved by food, 
as in ulcer. It is more a distress than a pain, with nausea and a 
sour, bloated stomach. The pain does not occur with regularity 
two to four hours after eating as in ulcer, nor is it relieved by food. 
The attacks are too lasting for gall-stones, and are without the severe 
pain. 

If the patient has ever had severe pain or tenderness over the 
appendix the diagnosis of chronic appendicitis may be suspected. 
In other cases examination of the blood and taking the temperature 
every evening (for slight fever) may throw light on the diagnosis. 
Sometimes only opening the abdomen will positively prove the cause 
of such stomach trouble to be a chronically inflamed appendix. 

The danger of such operation is slight in the hands of a skillful 
surgeon — one death in three hundred to four hundred operations. 

Treatment. — There is no medicine or other medical means capa- 
ble of curing appendicitis. Surgical removal of the appendix is the 

only remedy. 

FUNCTIONAL INDIGESTION 

{Faulty Development and Posture — Entero ptosis) 
This is by far the most important of all conditions causing indi- 
gestion, in fact, it is the most important problem in all medicine 
to-day because it is so common and has such unbelievably far-reaching 
consequences. 

In this class are included the weaklings of the human race 
and the sufferers from a great many other diseases which are 
secondary to the digestive disturbances. These include a very 
wide range of diseases, because the weakening effect of constant dis- 



518 



CHRONIC STOMACH TROUBLES 



ordered digestion makes the subject liable to all sorts of ailments. 
The medical term for the kind of faulty development and 
posture under discussion is enteroptosis. This means a falling- 
down of the abdominal organs from their proper position. There 
are two forms of enteroptosis, the form with which one of every 

five persons is born and that acquired by 
faulty posture. The faulty posture is al- 
ways seen in the first type, the reasons for 
which follow below. 

Symptoms. — It is easy for anyone to 
recognize enteroptosis by closely observing 
persons, even when they are clothed. It is 
not noticed in persons born with the trou- 
ble until they have been in an upright po- 
sition for some time — in other words, 
children four or five years of age. There 
is imperfect development of the child be- 
fore it is born so that, besides its physique, 
to be described, the intestines are com- 
monly much shorter than usual, sometimes 
only one-half the normal length, and are 
more loosely attached. Other anomalies 
are also present which make the internal 
organs sag when the patient is in an erect 
posture. 

Now as to the posture: — In standing, 
subjects of enteroptosis are stoop-shoul- 
dered and "pot-belHed," even when thin : 
that is, the shoulder blades project back- 
ward, the head is run forward, and 
when the subject is seen in profile (especially undressed), the abdo- 
men will protrude most below the navel (Fig. 58). This position is 
always taken in those born with enteroptosis, because the organs pull 
down on their attachments to the partition (diaphragm) separating 
the chest from the belly and also to a cord (cervical fascia) reaching 
up from the diaphragm to the back of the neck. 




Fig. 58. — E nteroptosis 
Showing Head Forward, 
Shoulder Blades and Low- 
er Part of Belly Prom- 
inent. 



FUNCTIONAL INDIGESTION 



519 



The faulty posture is taken by those who acquire it through 
laziness and ignorance (Figs. 59, 60 and 61) ; an enormous amount 
of harm may be caused by such a posture in producing dyspepsia 
and diverse diseases. If everyone would assume the military erect 
posture it is probable that more ill health and failure in life could be 
avoided than by any other possible preventive method now known. 
The person born with enteroptosis is also almost al- 
ways very thin and is the sort of person who would 
be likely to develop consumption. It is a fact that 
almost all cases of tuberculosis are found in persons 
born with faulty development, or enteroptosis, which 
we have been describing. 

With the clothes off other marked signs of en- 
teroptosis may be observed : a long narrow chest and 
long narrow abdomen ; then a very important point — 
the degree of angle formed by the coming to- 
gether of the margin of the ribs in joining the breast 
bone in front and at the upper part of the abdomen. 
This angle in the normal person should be broad, 
the lower border of the ribs sloping gently downward 
and backward to the spine (Fig. 63). In the sub- 
ject of enteroptosis the space is very narrow between 
the margin of the ribs in front and the latter run 
down almost vertically. This makes the chest long 
and narrow so that there is no room for the stomach and other or- 
gans where they belong — in the upper part of the belly — and they 
are crowded down (Fig. 62). Moreover, pressure, as by dress bands 
or tight corsets, about this region will still further aggravate the 
trouble. 

In profile the naked person will show even more the protrusion 
of the belly below the navel, whereas in the normal figure there 
should be a little more- protrusion above the navel and flatness 
below. 

Examination of the cuts will give one a better idea than any 
description possibly can. 

The stooping posture, in those born with faulty development 




Fig. 59. Faulty 
Posture, Fa- 
voring Enter- 
optosis. 



520 



CHRONIC STOMACH TROUBLES 



described, is due to the fact that there is not room in the upper part 
of the belly and the organs situated there are forced downward, 
pulling with them the diaphragm and a cord (cervical fascia) attach- 
ing the diaphragm to the neck. As the organs are also more poorly 
supported in these subjects of enter optosis they are more easily forced 
out of place. 

In acquired enteroptosis (Figs. 59, 60 and 61 ), through a stoop- 
ing posture assumed in normal persons, the organs are not displacel 

nearly so much, but the 
symptoms may be great- 
er owing to the fact that 
the attachments of the 
organs are firm and 
kinks and obstructions 
are more likely to exist. 
Diagnosis. — Exami- 
nation of the stomach 
by the doctor, who blows 
up the stomach through 
a tube to discover its 
size and position, is a 
common means of diag- 
nosis. More recently 
the x-ray has been used 
to take a picture of the 
stomach and bowels after the swallowing of some harmless metallic 
powder by the patient. This is the only exact method. But in de- 
termining the diagnosis of most cases the build and posture of the 
patient will be sufficient to determine the presence or absence of en- 
teroptosis. 

General Results. — Indigestion is due to a low position of the 
stomach, so that it does not empty itself properly in the upright 
position; also there is general lack of tone in these stomachs, and 
symptoms resulting from stagnation of food. 

The imperfect development in the bowels, where there may be 
but half the normal length of the portion where most digestion and 




Fig. 60. — Faulty Posture, Favoring Enteroptosis. 



FUNCTIONAL INDIGESTION 



521 



absorption of food occurs (small intestine), tends toward imperfect 

nourishment. The large bowels should normally have a fixed and 

uniform position, but in enteroptosis they sag so much that kinks and 

pouches form, leading to slow passage of the contents. This usually 

is shown by constipation, although there 

may be a daily passage, and yet some of 

the bowel contents may be delayed for a 

long time in pouches behind obstructions. 

The products of digestion, or in this case 

indigestion, from delay of the intestinal 

contents, may be absorbed into the blood 

and prove poisonous — with many diverse 

symptoms ( auto-intoxication ) . 

Various forms of joint and skin dis- 
ease and old age itself are thus favored. 
Sagging of the organs on each other 
causes absorption of the normal padding 
of fat in the abdomen from pressure, and 
the organs may press unduly on those 
great, vital nervous centers controlling 
the state of the blood vessels, with unfor- 
tunate consequences — such as high, blood 
pressure, etc. 

Sagging of the right kidney is com- 
mon with kinking of the duct for the es- 
cape of urine. This leads to attacks of 
great pain. Sagging of the liver is usual, 
and some cases of gall-bladder disease 

may be due to the obstructed circulation in this region. Cases of dia- 
betes have been recorded due to sagging of the pancreas. Finally 
the vitality is so lowered by interference with digestion that the 
subject, as we said in the beginning, becomes a weakling and is apt 
to succumb to such chronic diseases, as tuberculosis, and even to 
acute disorders, as infantile paralysis. 

Outlook. — Persons born with the enteroptotic physique are not 
robust and are apt to belong to the so-called "Nervous class" of pa- 




Fig. 61. — Faulty Posture, Fa- 
voring Enteroptosis. 



522 CHRONIC STOMACH TROUBLES 

tients and to develop many other diseases, as enumerated above — 
unless properly eared for. If these imperfectly developed persons 
are cared for, from early age especially, the probability of their ulti- 
mate health is very favorable. 

The object of this article is not to describe in detail such treat- 
ment as could be readily carried out by the reader; such is impos- 
sible and unnecessary, as the condition is not one of emergency, and 
will require the advice of an able physician. The object has been 
chiefly to draw attention to a most important defect which can be 
recognized by any observant and intelligent person, so that medical 
services may be obtained, especially for children who are very apt to 
inherit the enteroptotic physique from parents suffering from it. 
The treatment described will then be general and brief. 

General Treatment. — The general treatment of persons with en- 
teroptosis consists in making them assume the proper position, which 
means, standing erect as if trying to be as tall as possible, without 
standing on tiptoes, holding the- head erect, throwing the shoulders 
back, and holding the lower abdomen in. One should not lounge in 
chairs, as shown in cut (Fig. 60). or stand with the hands in the 
pockets, as in cut Fig. 59 . In sitting, the back of the chair should 
be a flat surface, sloping slightly backward so that the whole back of 
the person can be evenly supported. A belt which will support and 
press the intestines and stomach up into place is advisable in most 
cases in adults (^Fig. 64). 

In children shoulder and back braces are often required to secure 
the proper posture. The clothing in children should not be supported 
by shoulder straps, which cause the shoulders to droop forward; 
the bu] hotdd be obtained from straps passing just to the outer 

side of the root of the neck. It should be understood that not every 
patient who has been bom with, or who has acquired, enteroptosis 
suffers from it. 

The digestive symptoms are due to stretching of the stomach 
and loss of tone in the organ, or atony. Indigestion usually arises 
when there is general loss of tone or when the patient is "run down." 
If the health is generally good and attention is paid to correcting the 
faulty posture and to generally leading a healthy life, there may 



FUNCTIONAL INDIGESTION 



523 



never be any symptoms. This is the reason for training the young 
born with the faulty development of enteroptosis so that they may 
never suffer from the condition. 

About one in every six patients complaining of indigestion is 
suffering from enteroptosis, and for every male there are seven female 
sufferers. While the faulty devel- 
opment may be equally common in 
both sexes at birth, the relaxation 
of the abdomen following child- 
birth and the pressure of corsets 
and tight waistbands favors the 
downward displacement of the 
stomach and bowels — about twen- 
ty-five per cent, of women have en- 
teroptosis. 

Digestive Symptoms. — These 
are due to the sagging and stretch- 
ing of the stomach (atony), as not- 
ed above, and also to partial ob- 
structions of the bowel by kinking. 

The first symptoms often occur 
after some nervous strain, grief, 
or overwork, and the indigestion 
may only trouble the patient at 
times at first and then become con- 
stant. 

Gas in the stomach, with a feeling of weight and discomfort an 
hour or two after eating, are common ; nausea and vomiting of bile 
on occasions are also frequent. Headache, dizziness, loss of weight, 
insomnia and constipation may be present. In cases of long stand- 
ing the skin is stained a brownish hue. Most of the patients have 
many nervous symptoms. 

Treatment of Digestive Symptoms. — In addition to the constant 
wearing of a proper abdominal belt by day, the patient should lie 
down for two hours, if possible, after lunch. The position should 
be on the back with the shoulders and head somewhat raised, or 




Fig. 62. — Enteroptotic Build — Long 
Narrow Chest and Abdomen; Long 
Narrow Angle Between Rib Mar- 
gins. 



524 



CHROXIC STOMACH TROUBLES 



on the right side to favor emptying the stomach — since the lack of 
tone prevents the expulsion of food from the stomach in the proper 
time. The diet should be as recommended under Atony of the 
Stomach. 

In severe cases what is called the rest cure is recommended. In 
these cases the patient stays in bed for four weeks, having a special 
nurse who administers massage, electricity, and water or hydro- 





Fig. 63. — Normal Broad Chest — Wide 
Angle Between Rib Margins, Giv- 
ing W t ide Upper Abdomen. 



Fig. 64. — Belt for Enteroptosis — 
Straps Between Thighs to Hold 
It Down. 



pathic treatment, and gives frequent and abundant nourishment with 
the idea of very considerably increasing the weight of the patient. 
In all medical treatment of this disease gain in weight is the 
object chiefly sought. Drug treatment is much the same as for 
atony. 

The subject of indigestion with enteroptosis may have the con- 
solation of knowing that his trouble is probably functional, while 
the well-built individual who suffers from chronic dyspepsia is more 
apt to have ulcer, gall-bladder trouble, or chronic appendicitis — in 
other words organic disease. 



ATONY OF THE STOMACH 525 

ATONY OF THE STOMACH 

Atony means without tone. By tone is meant the elasticity of 
the living, normal stomach. Thus when food enters the normal 
stomach it does not fall to the bottom, as it would in a bag, but the 
natural resistance of the muscular wall of the stomach causes it to 
assume a cylindrical shape. As more and more food enters the 
stomach, instead of filling to the top, it broadens out above, as a 
certain amount of air always fills the upper part. In the stomach 
with loss of muscular tone the food does drop to the bottom and 
distends that part of the stomach, much as would happen if it were 
poured into a bag. 

Atony is one of the most frequent forms of dyspepsia occurring 
in 17 to 32 per cent, of the cases that present themselves for treat- 
ment for indigestion. 

Causes. — Nervous debility is the most frequent cause and as 
this goes hand in hand with enteroptosis, atony is present as a rule, 
in the latter disease. Too much eating and drinking, excessive use 
of alcohol and tea, and all sorts of debilitating diseases are causes. 
Heredity is the most frequent cause, that is, atony occurs most often 
in those born with a tendency to nervous weakness and faulty develop- 
ment, as previously described. 

Chronic constipation, the use of cathartics, and diseases of the 
female organs favor atony. 

Symptoms. — Gas is the chief complaint, both in the stomach and 
bowels. This causes a feeling of fullness, heaviness, and discomfort 
soon after eating. The greater the amount of food and drink the 
greater the following distress. The kind of food does not influence 
the result. 

The discomfort is worse for one to two hours after eating, and 
then it generally subsides. In severe cases there may be continuous 
discomfort, and the patient may be kept awake at night, or awaken 
early with it. 

The site of the discomfort depends upon the site of the stomach. 
Sometimes gas in the bowels is most prominent, and then discomfort 
below the stomach comes on two to four hours after eating and may 



526 CHRONIC STOMACH TROUBLES 

last during the night. Very rarely is there any actual pain, and if 
this exists it is probable that the trouble is not atony. In 'mild cases 
the discomfort is only felt after a hearty meal ; in severe cases distress 
occurs after every meal or most of the time. 

There is usually constipation. Sick headaches are common at 
various intervals. The pain begins in one eye, spreads to one side of 
the head, and nausea and vomiting come on: sometimes instead of 
this there is a dull headache at the back of the head. The trouble 
is aggravated by overeating or drinking, by starchy foods, and fruit. 
Palpitation of the heart is frequent, especially after lying down. 

Diagnosis. — Atony of the stomach does not usually occur in 
stout healthy looking persons, but in the thin and nervous and those 
having the signs of enteroptosis. Besides the symptoms already 
described there is usually a splashing sound heard on lightly tapping 
over the stomach with the fingers within three hours after eating 
and when the patient is lying down. If this sound is heard in 
persons with thin abdominal walls immediately after drinking »a 
glass of water, while fasting, it is a sure sign of atony. 

The other means of diagnosis are only open to the doctor who 
can tell by emptying the stomach five hours after the patient takes 
a cup of coffee, steak, and roll — because then the stomach should be 
practically empty. The finding of any amount of food remnants is 
a sign of atony. Food remaining in the stomach twelve hours after 
eating is, however, a sign of obstruction to the outlet, and not atony. 
The x-ray is the most reliable method of diagnosis. 

Course of the Disease.- — Many cases may be cured but, when 
once the disease becomes chronic, it is apt to recur whenever the 
patient is subjected to unusual nervous or physical strain. 

Treatment.— The patient with atony should not exceed his normal 
limitations, as to work or physical or nervous strain of any kind. 
The amount of food and drink at one time should be limited but 
enough food should be taken to sustain the weight and strength. 
Small meals and often is the rule. One should not drink more than 
half a glass of any liquid at a time between meals, nor more than a 
glass at meals. 

It is well to take a sandwich or crackers, and a glass of milk 



NERVOUS INDIGESTION 527 

or egg nog, during the morning and afternoon, and at bedtime. At 
breakfast — cereal, coffee and soft egg, or toast without cereal; for 
lunch — chop, or steak, or chicken, one vegetable, rice, tapioca, cus- 
tard or other simple pudding; for dinner — fish, chicken, chop or 
steak, mutton or roast beef, two green vegetables, and a simple pud- 
ding. Macaroni or spaghetti may be used in place of green vegeta- 
bles. A chicken or scraped beef sandwich may be taken between 
meals. Buttermilk or malted milk may be used in place of milk to a 
certain extent. 

The use of an abdominal belt in cases of faulty development is 
advisable, as previously recommended. Lying down for an hour or 
two after the noon meal may be necessary for a cure. Cathartics 
only increase stomach atony ; the use of a quart of warm soapsuds 
injected from a fountain syringe into the bowel, with the patient 
lying down, is the best remedy for constipation. 

The employment of a bitter tonic, such as the following, is of 
advantage: 

Formula for Bitter Tonic 

Tincture of nux vomica y 2 ounce 

Compound tincture of gentian IY2 ounces 

Compound tincture of cinchona 2 ounces 

Mix. 

Directions : Take one teaspoonful in one-quarter of a glass of water 
immediately before eating, three times daily. 

NERVOUS INDIGESTION 

Nervous dyspepsia has been thought quite frequent in the past, 
so that older medical authorities estimated 50 to 75 per cent, of all 
patients with indigestion to be suffering from this form. Recent 
authorities find but 3 to 15 per cent, of all patients with indigestion 
have the nervous form. Even this number may be cut down by 
improvements in methods of diagnosis. The trouble has been that 
cases of indigestion have not been carefully studied and the real 
causes of indigestion have not been discovered. We repeat the fact 
stated in the beginning of this chapter — that only 10 per cent, of 
all stomach troubles are actually stomach diseases and that 90 per 
cent, of stomach disorders are but disturbances of the stomach having 



CHEOXIC STOMACH TROUBLES 

their origin in disease of other parts of the body. When these 
causative diseases are cured the stomach trouble vanishes spon- 
taneously. 

How many unfortunate sufferers have for years led a wretched 
existence, have consulted numerous doctors, only to receive the ver- 
dict of "nervous dyspepsia."' but later have found out that ulcer of 
the stomach or a diseased appendix or gall-bladder was the offending 
organ. And with operation permanent recovery followed. 

A well-known case on record is that of a man who had suffered 
from so-called nervous indigestion for a long period, suddenly 
developing an unmistakable attack of acute appendicitis. His appen- 
dix was removed, but after recovery from the operation, the old pain 
again appeared. His surgeons therefore felt confident that the case 
had been and was one of nervous indigestion. Later, under the 
care of another physician, he was stricken with an acute attack of 
gall-stone colic and was again operated upon and the stones removed. 
Not long after the old pain in the abdomen recurred. At this time 
his doctors knew the trouble was nervous, for all possible causes 
had at last been removed; but the patient sought the advice of 
another practitioner who invoked the aid of the x-ray. and finally 
a stone was found in the right kidney. This being removed the 
patient became and remained a well man. It is probable that all 
three diseases existed at the same time and that a skillful operator 
could have cured all three at one operation. 

The blame for so many falsely diagnosticated cases of nervous 
indigestion must not be laid wholly upon the careless doctor, but 
failure in diagnosis is due in part to the fact that only recently have 
the symptoms of ulcer, gall-bladder disease, and chronic appendicitis 
become generally known by the profession, and furthermore to the 
fact that only recently has the use of the x-ray in diagnosis of 
stomach trouble been perfected. 

Certain features of dyspepsia point to a nervous origin ; thus 
persons with enteroptosis are the most common sufferers. The fact 
that the kind of food eaten does not in any way affect the trouble 
argues for nervous indigestion. Again nervous dyspepsia is worse 
when the subject is under nervous or physical strain and is apt to 



NERVOUS INDIGESTION 529 

disappear on change of scene and pleasant surroundings and circum- 
stances. 

Perhaps the most characteristic symptom of nervous indigestion 
is the variability of the discomfort. At times the patient is nau- 
seated ; then soon this is forgotten and the patient only complains 
of distention and weight in the stomach. In organic disease the pain 
is the same and in the same place constantly. 

Hasty eating has always been regarded as a' cause of indiges- 
tion, in that the food was not properly masticated and mixed with 
saliva. 

Pictures of the stomach during digestion, as shown by the x-ray, 
after a meal containing some metal as bismuth or barium, demon- 
strate that rapid eating causes dyspepsia in two ways : first, that too 
rapid dilation of the stomach by food will cause pain, and second, 
that considerable air is swallowed with the food when the latter is 
gulped down. TKe quantity of air or gas in the stomach is shown by 
a light area in the upper part of the stomach on the photographic 
plate. 

It would be foolish in a work of this kind to consider in detail the 
symptoms and treatment of nervous indigestion for, as we have seen, 
the essential matter is diagnosis, and this requires all the training, 
ability, and experience of the elect in medicine in order to eliminate 
all other possible causes of indigestion before it is proper to classify 
the case as nervous dyspepsia. The chief endeavor on the part of a 
patient with indigestion is to find a competent medical man who, 
besides taking a careful history and making a thorough examination 
of the body and stomach contents, will also employ the x-ray for 
diagnosis. No means at our command are superfluous, considering 
the difficulties involved in diagnosis of abdominal troubles. 



CHAPTEE III 
DISEASES CAUSING SEVEKE ABDOMINAL PAIN 



Acute appendicitis. Renal colic. Mucous colic. Sudden obstruction of the 
bowels. Peritonitis. 



Consideration of diseases in which there may be severe pain, 
including gall-stone colic and chronic appendicitis, will be found 
in the preceding pages. But under the head of severe pain is meant 
that which is practically unbearable — and only gall-stone colic fills 
this definition among the digestive diseases already discussed. 

GENERAL TREATMENT OF INTENSE ABDOMINAL PAIN 

It is advisable to summon a physician at once ; yet one must give 
relief to the patient, if a physician cannot be soon obtained. 

An immediate dispelling of the pain may be afforded by inhala- 
tion of ether or chloroform. Ether is the safer. It may be given 
by dropping it rapidly drop by drop from the bottle on a folded 
handkerchief placed over the mouth and nose. There is not the 
slightest danger in giving it this way, and when the patient starts 
to become unconscious the ether may be withheld. Or a towel may 
be folded into a cone and a tablespoonful of ether may be poured 
within the cone, which is then at once inverted over the nose and 
mouth of the patient, and the dose repeated every three to five minutes 
until the patient begins to become unconscious. 

Chloroform must be used with greater caution, but it may be given 
in single drops on a folded handkerchief over the patient's face. 

The handkerchief is held an inch or so from the patient's mouth, 
a fresh drop being allowed to fall on the handkerchief as soon as 

630 



TREATMENT OF INTENSE ABDOMINAL PAIN 531 

the previous one has evaporated. The chloroform may he dropped 
from a medicine dropper or from a bottle having a small gutter- 
shaped piece cut out of one side of the length of the cork. Fifteen 
drops of chloroform, if swallowed on a little sugar, will sometimes 
give relief from pain — but chloroform or ether must not at the same 
time be inhaled. The application of folded cloths wrung out in 
very hot water, and if possible sprinkled with turpentine and applied 
frequently to the abdomen will give much comfort. If a hot water 
bag but partly filled (to avoid weight) is laid on top of the wet ap- 
plication the latter will not have to be changed so often. 

Large hot poultices of flaxseed, Indian meal, bread, or any of 
the cereals may be employed. Rubbing the abdomen up on the right 
side across to the left at the upper part, and down on the left side, 
may aid the escape of gas from the bowels, if the belly is distended 
and not tender. A tablespoonful of whisky or brandy in hot water 
may be swallowed if there is faintness, but with vomiting no food 
or drink should be taken while the pain lasts. Sometimes changing 
the position lessens the suffering. When the pain is in one of the 
groins and back, and shoots down into the testicle, or toward the 
outlet of the vagina in women, great relief may be afforded if the 
patient lies in a hot bath. Some one should be present during this 
process, as sometimes the heat, pain, and nausea cause faintness and 
the patient may have to be helped out of the bath. 

There are certain names ignorantly used to cover the real condi- 
tion in which the true diagnosis is of urgent importance. Among 
these are ptomain poisoning, neuralgia of the stomach, and intestinal 
colic, which are frequently used as a cover for acute appendicitis, gall- 
stones, intestinal obstruction, and other conditions demanding instant 
surgical treatment. Such names should be used with the greatest 
hesitancy as they are misleading and often lead to unnecessary 
death. 

Violent abdominal pain cannot be set down to simple indigestion, 
even if the patient appears to wholly recover within a few hours. 
Such pain is due to organic disease of the abdominal organs, in 
most cases, and the cause should be sought for. Periodic attacks 
of pain, with perhaps long intervals of apparent good health, are 



532 DISEASES CAUSING SEVERE ABDOMINAL PAIN 

characteristic of gall-stones, appendicitis, stone in the kidney, etc. 
We shall consider under the head of diseases causing severe 
abdominal pain, acute appendicitis, renal colic, mucous colic, ob- 
struction of the bowels, and peritonitis, also gall-stones (already dis- 
cussed on page 506). Colic in babies and pains suffered by women 
in labor and during menstruation are treated elsewhere. 

ACUTE APPENDICITIS 

Causation. — Appendicitis is the most frequent and important of 
the causes of severe abdominal pain. It is more common between 
the ages of ten and thirty. 

The appendix is a blind sac into which the intestinal contents 
find their way and stagnate, and injury to the lining coat (mucous 
membrane) is readily brought about by retained secretions and 
dried contents. This damage to the mucous membrane in its turn 
allows germs, which are always swarming in the bowels, to enter the 
tissues and cause inflammation. Then the organ degenerates and 
disappears. Such organs are poorly supplied with blood and so 
can but feebly resist the inroads of germs. 

The disease has undoubtedly become more frequent of late years. 
Heavy lifting is a cause in some cases, and indiscretions in diet 
favor an attack — probably in both instances in those in whom the 
appendix is ' already diseased. Hardened balls of intestinal con- 
tents are probably common causes, as they are found in a large 
majority of cases of appendicitis at operation. There is no particular 
way in which one can avoid appendicitis and it appears to be preva- 
lent in certain families. 

The germs of some acute diseases find their way through the 
blood to the appendix, at times, and set up an attack — as is seen 
during typhoid fever, influenza, and tonsillitis. The old theory — 
that of grape seeds being a cause of appendicitis — has been exploded. 

Symptoms.- — Pain is the first symptom usually. It often begins 
about the region of the stomach and navel and shifts after a while 
to the right lower part of the belly or the region of the appendix. 
The pain begins suddenly in most cases, and is usually continuous 
and sometimes agonizing. 



TREATMENT OF INTENSE ABDOMINAL PAIN 533 

Nausea and vomiting usually follow the pain but may be 
absent. The bowels are commonly constipated, but there may be 
diarrhea, especially in children. The patient will lie with the legs 
drawn up toward the belly, so as to relax the abdominal muscles. 
The most important point in distinguishing this disease from others 
is the fact that there is tenderness over the inflamed appendix. 

The point of tenderness is in the lower part of the belly on the 
right side, usually nearly midway between the navel and the bony 
prominence of the right hip. The four fingers of the right hand of 
the attendant should be laid over this spot and then pressed down 
slowly but deeply with the left hand. This should also be done on 
the left side of the belly, so as to compare the two sides. Even when 
the pain is felt in the middle of the belly, it will be found that 
there is more tenderness on pressure with the hand of the attendant 
in the right lower part of the belly than at any other point. 

The muscle of the abdomen is also very rigid over the appendix 
as compared with that on the left side. 

The pulse and temperature are usually increased — the tempera- 
ture almost invariably during the first thirty-six hours of an acute 
attack. The pulse may be 80 to 120 or more, and the temperature 
from 100° to 102° F., or higher. 

The patient with appendicitis may (1) recover entirely and 
never have another attack, but this is rare; (2) may have the chronic 
form simulating stomach trouble which has already been described ; 
(3) may apparently recover wholly and yet have another attack at 
any time — this is the more common outcome; or (4) the attack may 
begin as described above, and the patient may die within twenty- 
four hours, or may continue in pain — slight or severe — and after 
some days a lump may form in the right side of the abdomen, and 
the latter may soften into an abscess. This may subside in a few 
weeks or break internally and cause death, or its contents may break 
into the bowels and be discharged this way, with recovery. 

Many other complications, too difficult for the layman to under- 
stand, may occur. The appearance in the course of the disease of 
chills, rapid pulse, general swelling and drumlike condition of the 
belly with anxious pinched countenance, cold sweats, and cold and 



534 DISEASES CAUSING SEVEBE ABDOMINAL PAIN 

blue hands and feet, are bad signs. The sudden disappearance of 
the pain may be a very bad symptom owing to gangrene or perfora- 
tion of the appendix. In this ease the pulse becomes rapid and 
feeble. 

Diagnosis.- — It is not within the power of the layman to make a 
positive diagnosis. There is no disease in which it is more necessary 
to summon a surgeon at the earliest possible moment after the occur- 
rence of the symptoms noted. Most cases having pain and tender- 
ness in the region described are appendicitis, especially in persons 
under thirty, but there are a number of other diseases which occa- 
sionally simulate appendicitis. 

Treatment. — There is no treatment advisable other than surgery. 
As soon as the diagnosis is positive the operation should be done in 
all cases in which the patient is not too sick to stand an operation. 
The most successful treatment consists in surgical removal of the 
appendix within twelve hours of the beginning of the attack. If 
this were the rule there would be practically no deaths. The delay 
caused by medical treatment is the only reason for death from 
removal of the appendix ; not only this but future attacks are abso- 
lutely prevented. Either the attending physician, the patient or his 
family or friends are usually responsible, through delay, for appen- 
dicitis resulting fatally, and the public should be so instructed. 

Statistics show that the death rate without surgery, when sur- 
gical attendance is not obtainable, is one in ten. The vital argument 
for early operation in acute appendicitis consists in the fact that 
the most skilled surgeon cannot tell by examining any individual case 
of appendicitis whether the patient will recover or not, because he 
cannot tell by any means at his command what the precise condition 
of the appendix is. 

If, however, the patient begins to steadily improve after the 
first two or three hours of sickness, one may feel confident of his 
recovery from that special attack. He should then be advised to 
have an operation after recovery, as another attack is probable and 
may occur where immediate surgery might be impossible. There is 
practically no danger from an appendix operation, when the patient 
is in general good health ; but most patients lose courage and choose 



TREATMENT OF INTENSE ABDOMINAL PAIN 535 

to take the risk of another attack rather than be operated when 
they feel perfectly well. 

When surgery is not employed the best treatment is rest in 
bed and starvation. This secures rest of the bowels, and is the surest 
mode of allaying the inflammatory condition. No more opium should 
be used than is essential to relieve pain. It is best if possible never 
to give opium in the presence of symptoms of appendicitis until the 
diagnosis has been made, as the drug obscures the symptoms and 
makes the patient feel as if he were getting well when he may be in a 
very critical condition. 

The patient should not rise from bed to pass urine or have a 
movement of the bowels, but should use a bedpan. 

No food of any kind should be given until four days after all the 
pain has subsided — if the attack has been severe and lasted over 
twenty-four hours. No food should be allowed in any attack while 
there is any pain. The first food should consist of broths, beef 
extract and strained thin cereals, which should be given for several 
days while th@ patient remains in bed. In severe attacks the patient 
may rinse his mouth with ice water, or hold ice in his mouth; in 
less severe attacks he may continually drink small sips of hot water. 

It is also well to give one-half pint of water containing one- 
quarter of a teaspoonful of salt, as an injection in the bowels, every 
four hours. The injection may be made with a fountain syringe, 
raised but six inches above the patient so that the water may flow 
slowly. 

Twice in twenty-four hours to replace these injections, an injec- 
tion containing either one beaten raw egg, with a pinch of salt and a 
teaspoonful of sugar in a cup of warm milk may be given, or as 
nourishment two tablespoonfuls of juice squeezed from slightly 
cooked fresh beef, in a cup of warm water, may be given. 

No cathartic of any kind is permissible during /an attack of 
appendicitis. After the pain has passed one may inject one-half 
pint of warm sweet oil into the bowel and this may be followed, in a 
few hours, by an injection of one quart of warm soapsuds to move 
the bowels. 

A rubber bag containing cracked ice, and applied over the seat 



536 DISEASES CAUSING SEVERE ABDOMINAL PAIN 

of pain, in the lower right quarter of the abdomen, is generally better 
than the use of hot poultices or cloths. However, when ice is not 
obtainable, hot poultices should be used throughout the attack ; these 
sometimes afford more relief than ice. Inability to pass urine is not 
uncommon, especially if much opium is taken. The application of 
hot cloths over the lowest part of the belly, and the injection into 
the bowel of a pint of water, as hot as can be borne comfortably, will 
usually assist the passage of urine. 

RENAL COLIC 

Causes. — Renal colic is caused by the presence of a stone in the 
kidney or in the narrow tube (ureter) which connects this organ 
with the urinary bladder; or colic occurs during the passage of a 
stone from the kidney through the ureter into the bladder. It is more 
common in men than in women or children. The precise cause for 
the formation of stone is unknown. 

Stone is extremely common in China and in some counties in 
England. In the United States it is moderately frequent and not 
confined to particular districts. The more common stones are of 
uric acid — which is a waste matter — resulting especially in those 
who are heavy meat-eaters, and who do not drink enough water or 
take sufficient exercise. The products of inflammation (mucus, pus, 
germs) may form a core on which the mineral matters are deposited 
to produce a stone. 

Symptoms. — The attack often begins suddenly. There is a con- 
stant dull pain felt in one side on the back just below the ribs, or 
below the ribs on one side of the abdomen, with agonizing attacks 
of pain shooting down into the groin, inner part of the thigh and 
testicle, on the same side. The pain is accompanied by nausea or 
vomiting, faintness, and sweating. At the same time there is fre- 
quency of urination which is often painful ; blood sometimes is seen 
in the urine. Its presence, with that of the pain just described, is 
a positive sign of renal colic due to stone. The pain may be felt 
as much on one side of the abdomen as in the back, and may spread 
all over the abdomen or even into the chest. 

The violent pain may last an hour, or for a day or more, with 



TREATMENT OF INTENSE ABDOMINAL PAIN 537 

intermissions. After the severe pain passes, soreness and aching may 
remain in the affected side below the ribs, front and back. Rarely 
is no urine passed during the attack. There may be a chill at 
the onset of the attack, and the temperature may rise to 101° or 
102° F. 

The stone may escape from the body in the urine or may remain 
in the kidney, ureter, or bladder. It is well to seek for the stone in 
the urine, for a week or more after the attack. If it lodges in the 
bladder there may be some pain in the lower part of the belly and 
frequent urination. With the continued presence of stone in the blad- 
der these symptoms persist, and the urine becomes cloudy with a 
white sediment of pus. 

In case of stone remaining in the kidney or ureter violent attacks 
or pain may not occur, such as have been described. It is not un- 
common in these cases that pain may be wholly absent, or appear 
at times in the upper part of the belly, or in the back, without shoot- 
ing downward. It is then perhaps difficult to distinguish the trouble 
from gall-stones or appendicitis, if the pain is on the right side. 

Following an attack of renal colic, and in doubtful cases of 
chronic pain in the abdomen, an x-ray picture should always be 
taken, in order that the presence of stone in the urinary tract may 
be known. 

When there is no pain the appearance of blood or pus in the urine 
should suggest stone. Persons with stone in the kidney often have 
attacks of chills and fever and general aching, at intervals of months 
and years, which are mistaken for grippe or malaria — unless the urine 
is properly examined. 

Diagnosis. — The location of violent pain in one side under the 
ribs and extending into the thigh and testicle, with drawing up and 
tenderness of the testicle, associated with frequency of urination, 
makes the recognition of renal colic a simple matter. If blood is 
present in the urine at the same time the diagnosis is practically 
certain. 

X-ray examination will positively determine the presence or ab- 
sence of stone, except in extremely fat persons. The passage of in- 
struments into the kidney by an expert, and the careful examina- 



538 DISEASES CAUSING SEVERE ABDOMINAL PAIN 

tion of the urine for microscopic blood, are of assistance in the diag- 
nosis. 

Treatment.' — Relief from pain may be secured by following the 
treatment recommended for severe abdominal pain (in this chapter), 
especially the use of a hot bath for the patient. Hot drinks, as hot 
water, or hot lemonade, are useful. If the patient will lie with 
his head to the ground, the stone will, in some cases, change position 
and relief will be secured. 

There may never be a recurrence of an attack of renal colic, or 
attacks may be frequent. This follows because after one stone es- 
capes, more may remain in the kidney or ureter. Even if a stone is 
present in the kidney it may cause no trouble for many years or dur- 
ing the patient's life, although this is not the rule. 

Since doubt must always exist as to the presence of stone, after 
an attack of renal colic, the use of the x-ray is always desirable al- 
though often refused by the patient after recovery. If stone is present 
surgical removal is advisable before inflammation of the kidney sets 
in — which is only a question of time. After inflammation has 
occurred, with pus in the urine, the operation is of greater gravity. 

The operation for stone in the urinary tract is not usually at- 
tended with much danger — providing the patient is in good condi- 
tion and the surgeon is skillful. 

The medical treatment consists in the drinking of large amounts 
of pure water — distilled, Poland, Bedford, or Saratoga — two quarts 
daily, and in taking three grains of lithium citrate in tablet form 
dissolved in a glass of water three times daily. No medicine or 
mineral water will have the slightest effect in dissolving stone al- 
ready formed in the kidney or urinary passages, but large quantities 
of water may assist in washing stones out of the urinary tract and 
relieving the irritation caused by them. With medicine, the effect 
of much water drinking is to prevent further stone formation. 

Outdoor life and exercise are necessary in effecting a cure, as 
also the absolute avoidance of alcohol in all its forms. Meat should 
be eaten in moderation, and not more than once daily. 

While appendicitis and gall-stones always require surgical treat- 
ment, the majority of persons suffering from renal colic pass the 



TREATMENT OF INTENSE ABDOMINAL PAIN 539 

stone and gravel and thus make a perfect and permanent recovery, 
although several attacks are frequent within the course of years. 
This more often is the case where the mode of life is not changed. 

MUCOUS COLIC 

This is a disease more common to nervous women than to men, and 
between the ages of twenty and forty-five. Most of the patients worry 
greatly over the disorder and are emotional, or are sufferers from 
nervous prostration, hysteria or melancholia. It is probably the re- 
sult of chronic constipation. The disease often lasts over a period 
of many years ; although there may be long periods of freedom from 
pain, it is very difficult to cure. 

Symptoms. — The peculiar feature of the disease is the painful 
passage of mucus from the bowels. This appears as a jelly-like sub- 
stance, or as slime, or at other times as white strings or strips, and 
rarely as a tubular membrane looking like a part of the bowel itself . 
The pain is caused by the severe contractions of the bowel in its 
attempt to expel the mucus, which sticks strongly to the sides of the 
bowel. There are often rumbling noises in the bowels and the 
mucus is expelled alone or mixed with excrement. The abdomen 
is not usually distended. The pain commonly subsides after ex- 
pulsion of the mucus and the patient may feel well for some time. 

The pain is often felt on the left side of the abdomen, and there 
may be a tender point between the navel and lower border of the ribs. 
However, sometimes the pain is on the right side in the region of the 
appendix and, without the history of expulsion of mucus in previous 
attacks, the disease may be taken for acute appendicitis. It is not un- 
commonly seen associated with chronic appendicitis, however. A 
nervous form of diarrhea may occasionally be associated with the 
passing of mucus. 

There is much straining during the passage of the mucus and 
nervous symptoms, as trembling, palpitation of the heart, and dizzi- 
ness may also be present. Constipation with some fullness of the 
bowels and poor appetite often persist between the attacks. Errors 
in diet, worry, and strong mental emotion tend to bring on an attack. 

The passing of mucus is not a sure sign of mucous colic. Mucus 



540 DISEASES CAUSING SEVERE ABDOMINAL PAIN 

may be passed in normal persons without having any significance. It 
is sometimes a sign of catarrh of the bowel, and in children it may 
be due to indigestion, and accompanied by some pain. Mucus and 
also blood are seen in cancer of the bowel. The diarrhea and passing 
of mucus in the disease called mucous colic is more often seen in 
the morning and is sometimes called "morning diarrhea." 

Treatment. — The essential treatment consists in the cure of the 
habitual constipation and building up the strength and weight. This 
disease had long been considered incurable until von Xoorden suc- 
ceeded in curing sixty out of seventy-six patients by the following 
treatment. Such treatment is most successful, however, when car- 
ried out in a sanatorium under the control of a physician. 

Pain is relieved by introducing a suppository containing one- 
third grain of extract of belladonna into the bowel and using com- 
presses of hot flannel on the abdomen. Suppositories are only used 
when pain is considerable, and one may be given two hours before an 
injection, if these are painful. The injection is given by raising the 
hips of the patient on a pillow while she is lying on her back. Then 
a quart of warm water, containing two teaspoonfuls of baking soda, 
is allowed to flow slowly into the bowel where it should be retained 
as long as possible. After it has come away one-half pint of warm 
olive oil is injected into the bowel, and allowed to remain two hours, 
when another injection of warm water is given. This comprises the 
treatment for the first day. Thereafter one injection of warm 
water and soda is given daily until the bowels move naturally with 
the use of a proper diet. Sometimes it is better to give an injection 
of one-half pint of olive oil at night to be retained until the bowels 
are washed out in the morning. 

The diet consists of much fat to build up the patient, and coarse 
food and fruits to move the bowels. Beginning at seven a. m., nour- 
ishment should be taken every two hours. During the day the patient 
should have five glasses of good milk and a pint of cream; most 
of the cream may be taken mixed with milk. There should be two 
regular meals — at one and seven p. m. 

At lunch the patient should take some kind of fruit having large 
seeds and thick skins, such as stewed currants, gooseberries, and 



TREATMENT OF INTENSE ABDOMINAL PAIN 541 

cranberries, or fresh grapes; and during the day she should consume 
about one-half pound each of butter and coarse graham or rye bread. 
Rest in bed for a week or so is advisable, at the beginning of the 
treatment. Some discomfort in the bowels will be felt until the 
patient becomes accustomed to the change of diet. In nervous and 
hysterical women, this treatment may be aided by giving an occa- 
sional pill of asafetida (five grains) ; this is harmless and will 
relieve flatulence besides having a soothing effect. 

SUDDEN OBSTRUCTION OF THE BOWELS 

This condition in adults is more commonly caused by com- 
pression of the bowel at some point, as when it is squeezed in the 
opening in the abdominal wall through which it passes to form a 
"rupture." Any rupture is at some time likely to be thus "strangu- 
lated" — and this is one of the chief reasons for operating on them 
rather than relying upon trusses. 

Causes. — A band of tissue resulting from a former inflammation, 
or operation, in the abdominal cavity may lead to obstruction. A fre- 
quent cause of obstruction in children is intussusception or a slipping 
of one portion of the bowel into a neighboring part, as one joint of a 
telescope slips into another. Twisting of the bowel on itself is still 
another source of obstruction, and even an almost knotted condition 
may at times occur. The existence of an accumulation of hardened 
excrement in the bowels, more often in the aged, may give rise to 
complete obstruction. Very rarely the presence of foreign bodies, 
which may have been accidentally swallowed, or gall-stones, may ob- 
struct the bowels. 

Obstruction of the bowels is not a common disease. 

Symptoms. — Pain, vomiting, persistent constipation — these are 
the three symptoms. The pain is more often about the navel, be- 
ginning suddenly. It is at first intermittent, but later continuous. It 
varies in intensity from moderate to excruciating pain. In vomiting, 
the contents of the stomach is first expelled ; next we see bile or green- 
ish fluid, and last — in three to five days after the onset — a brownish 
black substance having an unmistakable odor of human excrement. 
This sequence of symptoms is characteristic of obstruction. Con- 



542 DI-I.-I- CAUSING SEVEBE ABDOMINAL PAIN 

stipation is complete, but in most of the eases of intussusception 
in children there is an escape of bloody, s lim y material from the 
bowels, with much straining: or blood is seen in returning rectal in- 
jections. Fever is often not present. 

^irh the free passage of either gas or excrement one may be 
sure that the ease is not one of complete obstruction. The belly is 
often much distended with gas, and although not tender to the touch 
at first, it rapidly becomes so. A lump may be felt in the belly, espe- 
cially in children. 

The e~ee: :£ obstruction of the ";:~0- ; on the general condition 
is marked. There is great prostration, feeble, rapid pulse, cold hands 
and feet, anxious, sunken features and cold sweats. If the obstruc- 
tion is not relieved the patient will not live more than three to six 
days. Absolute constipation, with constant vomiting and tenderness 
and distention of the belly, often occur in other conditions than ob- 
struction of the bowels, as in appendicitis and peritonitis. In neither 
is the vomiting of excrement ever seen, and the former two begin with 
fever and tenderness in the belly. 

Treatment.- — In addition to "he use of opium and external heat 
as advised in the beginning of the chapter, injections of warm water 
should be given into the bowel with the patient on fa :. and hips 

raised on a pillow. The water should be allowed to flow from a 
fountain syringe raised :_ree feet above the patient — as much as six 
quarts at a time for adults. .one and one-half pints for infants — 
and the injections should be given three times daily, the patient being 
encouraged to retain the water as long as possible. If the obstruction 
is due to excrement it will be overcome, and sometimes other forms 
of obstruction as well — this includes almost one-half the cases in 
children. 

The layman should never treat such a condition if he can help it. 
A surgeon should be secured at the earliest possible moment, as only 
early operation will save the patient in case he does not at once re- 
spond to injections or inflation of the bowels with air. In severe 
3asefl time should not be wasted in medical treatment. Cases of ob- 
struction of the bowels are more commonly cured by surgery than 

medical mea: is. 



TREATMENT OF INTENSE ABDOMINAL PAIN 543 



PERITONITIS 

(Inflammation of the Bowels) 

Peritonitis is an inflammation of the membrane which covers the 
inside of the cavity of the belly, and also the stomach, intestines, and 
other organs within the cavity. 

Causes. —Very rarely peritonitis starts as such from blows on the 
belly or exposure to cold, but it almost invariably is secondary to in- 
flammation of one of the organs within the belly, which extends to 
the covering of these organs, and then to part or the whole of the 
membrane (peritoneum) lining the belly cavity. Wounds penetrat- 
ing the wall of the belly, accidental or surgical, not infrequently 
cause peritonitis. 

Excluding these, the disease in the male is more frequently due 
to acute appendicitis, and in the female to appendicitis and inflam- 
mation of the ovaries and fallopian tubes, following infection from 
childbirth, miscarriage, etc. Typhoid, dysenteric and cancerous ulcer- 
ation of the bowels, simple ulcer of the stomach and first part of 
the bowel, and inflammation of the gall-bladder, may lead to perfora- 
tion of these organs and to the escape of germs into the belly cavity, 
where they cause acute inflammation of its whole inner surface, or 
peritonitis. 

Peritonitis may be acute or chronic, general or local. The acute 
general form is described below. The local form is often found in 
inflammation about the fallopian tubes and womb in women, and does 
not ordinarily spread to a general peritonitis nor become fatal. So 
too there may be a local peritonitis in an acute appendicitis which may 
be arrested by operation. The danger of acute appendicitis if not 
operated, is chiefly of a general peritonitis. 

Symptoms of Chronic Peritonitis. — Chronic peritonitis is seen 
more often as a result of tuberculosis, and is frequently found in 
persons who have already had tuberculous trouble in the chest. It is 
of long and uncertain duration and may terminate in recovery. There 
is pain, vomiting, constipation, often distention, and tenderness in 
various parts of the abdomen. There is fever on occasions. Some- 



544 DISEASES CAUSING SEVERE ABDOMINAL PAIN 

times fluid accumulates in the belly cavity, and in these cases opera- 
tion is very successful. There may be a lump or tumor felt in the 
abdomen. The patient is often up and about part of the time. 

Symptoms of Acute Peritonitis. — Peritonitis in most cases be- 
gins with intense pain in the abdomen. The site of pain in the 
beginning depends upon the location of the organ in which the trouble 
originates — if in the appendix, there is pain in the lower right quar- 
ter of the abdomen; if in the sexual organs of women, the pain is 
low down in the abdomen, in the middle, or to the right or left. 

The pain soon becomes general and continuous over the abdomen 
instead of in paroxysms as in colics. The pain may lessen as the 
disease progresses, but the abdomen becomes very tender to pres- 
sure, distended, and drumlike. The pain is made worse by move- 
ments, and the patient lies on his back, with knees drawn up toward 
the belly to relax the abdominal muscles. Vomiting is constant and 
produces much pain. At first whatever happens to be present in 
the stomach is expelled, later a greenish or yellowish fluid, and finally 
a brownish or blackish fluid is brought up. The bowels may be 
loose at first but become constipated. The pulse is rapid (110 to 
150), and the temperature may be increased to 100° or 103° F. 

The appearance of the face is very characteristic. It is expres- 
sive of much suffering and anxiety, the eyes are sunken, the fea- 
tures pinched and often bluish in hue, the nose sharper. The breath- 
ing is weak and the skin cold. 

General acute peritonitis is one of the most fatal diseases, death 
occurring in from thirty-six hours to ten days. 

Diagnosis. — The history of any previous disease in the abdomen 
may aid in the diagnosis, and also throw light on the origin and 
treatment. The differentiation of this disease from others in the 
abdominal cavity is not within the power of the layman. It is evident 
that a patient with symptoms at all suggestive of peritonitis cannot 
secure the services of a physician too quickly. 

Treatment.— Surgery offers almost the only hope in acute general 
peritonitis. This is especially true of peritonitis following perfora- 
tion of the appendix, or of ulcer of the stomach and bowel and of 
the intestines in typhoid fever. Murphy, of Chicago, has reversed 



TREATMENT OF INTENSE ABDOMINAL PAIN 545 

the results in peritonitis following appendicitis by curing most cases 
where formerly most died. This form of surgical treatment has 
been commonly adopted. When a medical man cannot be obtained 
the same treatment should be followed as advised in this chapter 
in the care of Appendicitis. 

Opium may be used more frequently and in sufficient amount to 
keep the patient fairly comfortable. No cathartics should be given. 
To relieve the distention of the belly, a quart of warm soapsuds may 
be injected at frequent intervals into the bowel, and a tablespoonful 
of turpentine may be added to aid the expulsion of gas. Cloths 
dipped in turpentine and then w T rung out in hot water, or cloths 
dipped in ice water, should be applied to the abdomen at frequent in- 
tervals throughout the disease. Sometimes the one, at times the 
other, gives more relief. 

As convalescence may be protracted, if the patient recovers, his 
strength must be supported. It is permissible to feed him, if vomit- 
ing is not too frequent. One-half cupful of milk may be given every 
two hours, varied by juice squeezed from hot, rare beef, or white 
of egg stirred in cold water. Cracked ice held in the mouth will 
tend to prevent vomiting. 



CHAPTER IV 
DIAEEHEAL DISEASES— CONSTIPATION 

Disease of adults, including acute and chronic diarrhea, acute and chronic 
dysentery, cholera morbus, Asiatic cholera, and constipation. Diseases 
of children, including simple diarrhea or acute intestinal indigestion, 
summer diarrhea of infants, cholera infantum, and constipation. 

DISEASES OF ADULTS 

ACUTE AND CHRONIC DIARRHEA 

Causes. — Diarrhea is brought on by the most various causes, 
among which are the following: stomach disorders preventing com- 
plete gastric digestion, especially with deficiency of acid ; acute germ 
diseases, as typhoid fever, cholera, and cholera morbus ; errors in diet, 
as eating of unripe fruit, special articles of food, and taking certain 
kinds of drinking water ; changes in temperature which lower the vi- 
tality, as exposure to excessive heat, especially in children. 

Chemical poisons are common causes of diarrhea, as those formed 
in decomposing meat and fish and overripe fruit, and in improperly 
prepared canned goods ; in decomposing animal and vegetable foods, 
but particularly in milk and its products, as in ice cream, cream 
puffs, etc. The last is the chief cause of infant mortality, i. e., germ- 
laden milk which produces the summer diarrhea and cholera infantum 
of children. 

Still other causes are the exposure of the abdomen to cold when it 
is insufficiently covered ; chemical poisons taken accidentally or with 
intent ; diseases of the heart, liver and lungs causing congestion of 
the bowels; diseases leading to impoverishment of the blood, as in 
cancer, anemia and Bright's disease; diseases producing ulceration 

546 



DISEASES OF ADULTS 547 

of the intestines, as dysentery, cancer and occasionally tuberculosis. 
Certain intestinal parasites, especially in warm climates, are common 
causes of diarrhea. 

Finally there often appears to be a purely nervous origin of 
diarrhea due to emotion, anxiety, fright, and overstrain in those of 
a nervous temperament. This is seen not uncommonly in the sudden 
diarrhea of students before examinations, in surgeons before under- 
taking serious operations, and in women with mucous colic. 

One of the common causes of severe diarrhea with pain and vomit- 
ing is said to be ptomain poisoning. A ptomain is a chemical poison 
which may be generated by putrid meat or vegetables, but the word 
is used indiscriminately by many doctors in the case of persons 
suffering from acute abdominal pain, vomiting, and diarrhea when 
they are really attacked by appendicitis, gall-stones, abdominal ob- 
struction, etc. The term ptomain poisoning is employed so carelessly 
that careful physicians have come to suspect this diagnosis unless a 
number of persons are affected about the same time with symptoms 
after eating some suspicious putrid animal or vegetable food. In a 
large number of cases of acute. and chronic diarrhea the cause is 
wholly unknown. 

Without tuberculosis in the chest, a diarrhea is almost never due to 
tuberculosis, and it often occurs in consumption without any apparent 
local disease of the bowels, as ulcers. In many cases chronic diarrhea 
seems to be due to overwork and overstrain. 

Symptoms.' — Diarrhea consists of frequent, soft, watery move- 
ments from the bowels, varying from two to three, or twenty or 
more discharges daily. It is commonly due to catarrh of the mucous 
membrane lining the bowels, and this and other causes increase the 
nervous irritability, movements, and secretions of the bowels so that 
their contents are expelled more rapidly than usual, and therefore 
in a more liquid state. The color of the passages is commonly light 
yellow but may be greenish, from excess of bile, or slimy from 
mucus, or colorless and watery. In case there is actual ulceration of 
the bowels, blood and pus may be seen in the movements. 

Diarrhea is often accompanied by pain, either continuous or oc- 
curring with the movements of the bowels, and sometimes by fever 



54S DIAERHEAL DISEASES— CONSTIPATION 

^temperature 101°-102° F.), nausea, loss of appetite, and vomiting. 
Karely there are cold sores on the lips, and pain in the muscles and 
joints occur. There are no positive signs by which the seat of the 
trouble in the intestines can be localized. 

It is often taught that when the discharges are yellowish or 
greenish-yellow, containing food remnants and a little mucus, and 
associated with colicky pain, that the seat of the trouble is in the small 
or upper intestines, and that diarrhea originating in the lower or large 
intestine (colon) gives rise to grayish, soupy discharges with mucus. 
We have no certain means of distinguishing the site of the trouble, 
however, unless there is much straining with the passages, when the 
inflammation is in the rectum or lowest part of the bowels. 

The chronic diarrhea which appears more often in the morning 
is more apt to be due to nervous causes, as overwork, loss of sleep, 
worry, etc., to deficiency of acid in the gastric juice, or to mucous 
colic. Cabot says the cause is unknown in many, or most, cases of 
diarrhea since there is no anatomical or other cause apparent. He 
believes these doubtful cases due to nervous disturbance causing al- 
teration in the blood supply of the bowels. Where blood and pus 
occur of course ulceration exists in the bowels, but in one-half the 
cases of ulceration there is no diarrhea. 

In cases of chronic diarrhea which have lasted several weeks, the 
stomach contents should be examined for deficiency of acid, etc., the 
discharges should be examined for blood, pus, and parasites, and 
the inside of the lower bowel should be examined through an instru- 
ment called a proctoscope. The appearance of mucus in the bowel 
movements does not possess any special significance. 

' Chronic diarrhea leads to depression of spirits, general weakness, 
emaciation, and anemia or pallor. However, the fact that diarrhea 
has been chronic for a long time is no reason why it may not be readily 
cured, unless there are pus and blood in the discharges, showing 
ulceration. 

Treatment. — There are three essential points in the treatment of 
diarrhea : rest, diet and the use of cathartics. 

In no other disease is rest in bed more important or of more 
value. After months, or even vears of treatment, nianv cases of 



DISEASES OF ADULTS 549 

chronic diarrhea will recover at once on being put to bed, without any 
other treatment. It is only in the severe cases of diarrhea that 
the patient need go to bed, however. In the acute attacks of diarrhea 
no solid food should be taken. Three tablespoonfuls of castor oil 
should be given to adults ; children, one to two tablespoonfuls. 

A tablespoonful of Epsom salts, in as little hot water as will dis- 
solve it, may be taken and followed at once by a whole glass of water, 
instead of the castor oil ; but this is hardly as efficient. 

The diet should consist of a glass of boiled milk every two hours, 
at first, and then of gruel made by boiling flour in milk, alternating 
with boiled rice and milk toast made with boiled milk. If nausea 
and vomiting are present, a teaspoonful of cracked ice with a few 
drops of brandy may be swallowed at frequent intervals. Water is 
permissible in all cases, but in small quantities at a time. 

Pain in the abdomen is treated by applications of hot towels or a 
mustard poultice of flour (3 parts) with mustard (1 part), mixed in 
a thick paste with warm water, and spread between one foot square 
pieces of old cotton cloth; or flannel wrung out in turpentine and 
afterwards in hot water. 

The best drugs to stop the diarrhea are bismuth subcarbonate — 
one-half teaspoonful every three hours on the tongue, or chalk mixture 
— one tablespoonful every two hours, as long as the attack lasts. 
Both these drugs are absolutely harmless. 

If the attack lasts several days it may be necessary for the patient 
to take opium in some form, as paregoric 1 (one teaspoonful), or lau- 
danum 1 (ten drops), given twice daily. A warm flannel bandage, 
one foot wide, about the belly, will aid recovery. If the bowel dis- 
charges are frequent and watery and do not cease under the treat- 
ment just advised, tannalbin may be given in ten grain doses on the 
tongue thrice daily, along with paregoric. 

The diet in chronic diarrhea is much the same. Bismuth is also 
one of the best remedies, as advised. When milk does not agree, the 
whites of two raw eggs may be stirred into one-half a glass of cold 
water, and flavored with a little sherry, and this may be given in 

1 Paregoric and laudanum are preparations of opium only to be obtained by 
a doctor's prescription. 



550 DIARRHEAL DISEASES— CONSTIPATION 

alternation with broths or strained gruels of barley, oatmeal, or rice. 
Change of climate is often of most service. 

In the acute form of diarrhea the daily injection into the rectum 
of one quart of warm water, containing one teaspoonful of com- 
mon salt, may be useful : but in chronic diarrhea the use of injec- 
tions is more particularly valuable with ulceration of the bowel, as 
shown by slime or blood in the bowel discharges. The patient's hips 
should be raised in bed by a pillow under the lower part of the 
back, and a quart or two of warm water should be allowed to now in 
slowly from a fountain syringe hung some two feet above the patient : 
the injection should be retained as long as possible. They may be 
given once daily. 

Thirty grains of silver nitrate dissolved in one quart of water makes 
one of the best injections, also lead acetate i sugar of lead i. boric acid. 
or sulphate of copper | blue vitriol) in the proportion of one teaspoon- 
ful to one quart of water may be used to advantage. If these injec- 
tions do not relieve the trouble at once it is not wise to continue them. 

As has been said, in many cases after taking to bed a chronic 
diarrhea may at once disappear. 

ACUTE AND CHRONIC DYSENTERY 

This is an inflammation of the lower bowels I chiefly), manifested 
by eolie and frequent painful passages of blood and mucus, with 
much straining — in the acute cases, and by diarrhea, alternating with 
constipation — in the chronic forms. 

There are two forms depending upon the cause. In one the cause 
is a microscopic form of animal life, the ameba. 

Amebic dysentery is most common in the Southern States and in 
the tropics, but is also found in temperate states. The other form 
is due to several varieties of a vegetable germ or bacillus, and is 
called bacillary dysentery. This latter type is the cause of epidemics 
of dysentery in the tropics and is the more common cause of the 
dysentery occurring in late summer and autumn in temperate parts 
of the United States: it is frequently the cause of severe siunmer 
diarrhea of children. 

In military camps dysentery has proved more fatal than shot and 



DISEASES OF ADULTS 551 

shell ; it is very severe in the tropics and has been the cause of a 
large part of the sickness among soldiers in the Philippines^ Porto 
Rico, Cuba, and South Africa. At the present time there is a vac- 
cine which may be used to prevent the bacillary form of dysentery. 
It is prepared in the same way and given in the same doses as typhoid 
fever vaccine, and there is also a serum valuable in the treatment of 
this form of dysentery. 

Cause. — The germs of either form of dysentery enter the mouth, 
chiefly in water contaminated by bowel discharge. Milk products 
are a source of infection when contaminated with polluted water. 
Attendants handling patients, especially babies, may infect food; 
flies are carriers of dysentery germs. Persons who have recovered 
may for some time pass the germs in their bowel discharge. 

Symptoms. — One cannot discriminate merely by the symptoms 
between the form of dysentery caused by the ameba and that by the 
bacillus. Only microscopical examination of the bowel discharges 
and blood tests can determine the precise cause. 

In the more common variety in the United States the disease 
begins with slight pains in the abdomen and diarrhea, at first free 
and painless. Within thirty-six hours there are frequent passages of 
slime and blood, and small masses of excrement — from fifteen to two 
hundred movements in twenty-four hours. The movements are 
accompanied by much pain in the abdomen and straining. There 
is a constant feeling of unsatisfied desire so that the patient is 
continually running to the closet, or is inclined tO' stay there for an 
indefinite time. Fever, usually moderate (102° to 103° P.), coated 
tongue, rarely a chill at the onset, and occasionally nausea and vomit- 
ing, are also accompaniments. 

After the end of a week the blood usually disappears, and the 
passages consist of soft, greenish matter, with slime ; but these gradu- 
ally regain a normal appearance, so that in most cases recovery en- 
sues within ten days. In epidemic dysentery or tropical dysentery 
the course is often severe and not infrequently fatal. 

Beginning as described above, the passages consist soon of blood 
and mucus, or blood alone. The fever is high (103° to 104° P.), 
there is great straining and pain and constant desire to move the 



552 DIARRHEAL DISEASES— CONSTIPATION 

bowels, and cramps in the arms, legs, and muscles often occur. The 
joints may become swollen and painful. 

The pulse becomes weak and rapid, thirst is intense, the tongue is 
coated, and great weakness and even delirium appear. If improve- 
ment takes place these symptoms abate, the fever and frequency of 
the passages lessen, and the patient will be on the road to recovery iu 
two or three weeks, unless the disease becomes chronic. 

The latter form is unfortunately only too common, owing often to 
unsuitable surroundings, or improper care or food, and may persist 
indefinitely unless these conditions can be improved. 

Liver abscess often follows Ions: after the amebic form of dvsen- 
tery has apparently recovered. Ipecac treatment will prevent it. 

Treatment. — The preventive treatment is the same as that de- 
scribed for typhoid fever. Quiet and absolute rest in bed are impera- 
tive, even in chronic cases. The patient must then of course use a 
bedpan and the attendant employ the same care as in typhoid fever. 

The diet is most important and, for the first few days, should 
consist of white of egg and water, broths, whey, rice water, and 
strained gruels. The addition of milk sugar to drinks improves their 
nutritive value. After a few days boiled milk may be used, and 
later, soft eggs, milk toast, and cereals. Juice squeezed from rare 
beef may be given at first, and strained rice and barley gruels may 
be added to broths. 

At the beginning of the attack two tablespoonfuls of castor oil, or 
a heaping tablespoonful of Epsom salts should be taken in a glass 
of hot water. If a physic has not been employed in the beginning, 
the oil should be taken later, as it is necessary to clear out the 
intestines notwithstanding the frequency of movements. Hot cloths, 
overlaid with a hot water bag, or hot light-weight poultices, may be 
frequently applied to the belly to relieve griping and distress. To 
also assuage the pain one-half teaspoonful of laudanum 1 may be in- 
jected into the rectum in one-half cup of warm starch solution (made 
by boiling starch in water), and repeated every few hours if neces- 
sary. When the solution is not retained, a teaspoonful of paregoric 1 

1 Laudanum and paregoric are preparations of opium and can only be 
obtained by a doctor's prescription. 



DISEASES OE ADULTS 553 

may be given in water by the mouth every two hours to relieve the 
pain. Bismuth subcarbonate may be taken every two hours in one- 
half teaspoonful doses on the tongue. 

Ipecac is the most valuable remedy in dysentery and should be 
given in capsules of keratin, or salol coated pills, at night in one 
dose, three or four hours after eating, and the patient should be put 
on a milk diet. This treatment is as useful in the chronic form. Be- 
ginning with sixty grains at night the dose is cut down to five grains 
each night, until ten grains are given. This treatment is of most 
value in the amebic form, but is of service in the other as well. The 
active principle of ipecac (emetin) gives still more successful results 
when injected subcutaneously, and especially in amebic dysentery. 

In the acute stage the daily injection of a quart of warm solution 
containing a teaspoonful of salt in a pint of water, is valuable, and 
later the use of other solutions. It is advisable to give an occa- 
sional dose of castor oil or Epsom salts in the chronic forms. When 
the disease tends to become chronic the patient should be kept in 
bed, with a warm flannel bandage about the belly, and take only 
boiled milk and broths, with rice and barley added, white of egg and 
water, and soft eggs. 

The injection of a quart of kerosene every other day has been 
found wonderfully curative. The patient is placed face downward 
in bed, resting on his knees and chest while the kerosene is allowed to 
flow slowly into the bowels through a rectal tube or large catheter at- 
tached to a fountain syringe. In addition, from one to three grains of 
emetin are daily injected under the skin by a doctor. This treatment 
is especially successful in the amebic form of dysentery. 

In the bacillary form, or when the cause is unknown in chronic 
dysentery, some of the preparations of silver are useful — as the 
daily injection into the bowel of fifteen grains, and later thirty 
grains, of silver nitrate dissolved into a pint of water. Three pints of 
this solution should be injected at one time from a fountain syringe 
held but two feet above the patient, in the position described above, 
which allows the fluid to flow far up into the bowels. The fluid should 
be retained from fifteen to thirty minutes, if possible. 

Drugs by the mouth are not of much value. Change from the 



554 DIABBHEAL DISEASES— COXSTIPATIOX 

diet advised to ordinary food should be very gradual, especially avoid- 
ing fruits and coarse vegetables. During epidemics only boiled water 
should be taken, and bowel discharges should be disinfected as in 
typhoid fever. 

CHOLERA MORBUS 

Causes. — Cholera morbus is an intense inflammation of the inner 
coat of the bowels (enteritis) due to poisons in decomposing food. 
These may be already preformed in food or water, or, owing to the 
food being indigestible, the decomposition may occur within the 
bowels. All decomposition is due to germs. There does not appear 
to be any special germ, however, responsible for this disease. 

It is caused then by eating indigestible food, such as raw vege- 
tables, salads, unripe or overripe fruit, tainted fish, shellfish, meat, 
and impure water. 

It is a disease of hot weather occurring more often at night and 
in healthy, young adults. Chilling of the skin after a hot day, over- 
fatigue, and the drinking of fermentable liquids, as beer, predispose 
to the disorder. 

Owing to its violence it may be called the cholera infantum of 
adults. It comes nearer to the popular ptomain poisoning than any 
other recognized disease. 

Symptoms. — Cholera morbus comes on suddenly. The patient 
is seized with a feeling of oppression in the stomach, and nausea, fol- 
lowed by violent vomiting, and diarrhea. In severe cases, watery dis- 
charges escape in large amounts from both the stomach and bowels, 
like the rice water diarrhea in true Asiatic cholera. Violent pains 
in the belly occur, and cramps often attack the calves of the legs 
and other parts of the body. Thirst is intense from loss of water. 
The patient is greatly exhausted by pain, the loss of fluid from the 
blood, and the general poisoning. The face becomes pinched, the 
eyes sunken, the pulse rapid and weak, the voice feeble, skin cold 
and clammy, and the lips, hands and feet blue. In other words 
more or less collapse is present. The belly is generally tender, the 
patient lying on the side or back with the legs drawn up. Fever 
occurs, as will be observed by placing a thermometer in the bowel. 
The disease usually lasts twelve to twentv-four hours, or longer, but 



DISEASES OF ADULTS 555 

recovery commonly occurs within a few days. Occasionally diarrhea 
persists for some time. Death is rare, but may occur in the old or 
weak. 

Diagnosis. — In severe forms the symptoms cannot be distin- 
guished from true Asiatic cholera. The latter is a very fatal con- 
tagious disease which has not been known in England or the United 
States since 1873, except in a few cases brought by ships to quarantine 
in the seaports. Only microscopic examination of the bowel dis- 
charges enables the physician to diagnose true cholera by the dis- 
covery of the cholera germ. Cholera morbus is not in the least con- 
tagious. 

Attacks of appendicitis sometimes begin with diarrhea, as well 
as vomiting, abdominal pain and fever. The tenderness is then in 
the region of the appendix in the lower right side of the belly and is 
not general, as in cholera morbus. But as the early recognition of 
appendicitis is of vital importance it follows that a doctor's aid should 
always be secured. 

Treatment. — Opium in some form is the essential remedy. As the 
patient is continually vomiting and purging, it is impossible to obtain 
a satisfactory result except by injecting one quarter grain of mor- 
phin * under the skin. But this is precisely what the layman gener- 
ally cannot do, so that medicine must be given by the layman through 
the mouth or bowel. 

Ten drops of laudanum, 1 or a tablespoonful of paregoric, 1 should 
be given in a little ice water and, if soon vomited, the dose should 
be immediately repeated — even a third time, if the second dose is. 
rejected. If the medicine is retained in the stomach it should be re- 
peated every hour until the vomiting, purging, and pain are re- 
lieved. If the medicine is not retained, twenty drops of laudanum 
in one-half a cupful of warm boiled starch and water may be in- 
jected into the bowel, and repeated in the same manner. The giving 
of small doses of brandy, one tablespoonful in cracked ice half hourly, 
and the application of heat to the belly by poultices, and hot drinks, 
tend to prevent collapse. 

i Powerful drugs, such as morphin, paregoric and laudanum, can only be 
obtained by a doctor's prescription. 



556 DIARRHEAL DISEASES— : -IIPATION 

TETJE C7HOLERA 

True cholera originated in India and : b : revalent in hot ; ■ : nnfries. 
In the United Stu.:t~ and England it has not prevailed ainee 1873, 
although occasional cases have been brought m ahi] 
stopped in qnarantine in seaports of these countries. It has heen 
common in the Philippines and Manila, but is now well under con- 
trol there. Cholera occnrring in warm weather is usually, but not 
always, cheeked by frost. 

Causes. — Intemperance, debility, indigestion, overexert ion, weak- 
ness, and unhygienic surroundings predispose to the disorder. The 
only cause of eholera is a special germ, the "comma badDus/' which 
is found in the bowel discharges, but which rarely enters the blood. 
It enters the patient in food or drink. Doctors and nurses do not 
often contract the contagion if they practice cleanliness, as the 
germ is present in the stomach and bowel discharges, and by keeping 
the hands free from contact with these, and by thorough washing 
after contact with the ::ent, and by disinfecting his clothing, bed- 
ding and uten- ^ langei of acquiring the disease is slight. 

Symptoms. — The symptoms appear two to five days after the 
germs enter the digestive tract. These symptoms are often not so 
severe at first as in our cholera morbus. Headache, colicky pains, 
diarrhea, and general depression may be present for a day or two 
before the severe stage, the latter may appear suddenly. 

The bowel discharges resemble whey or rice water in appearance, 
have a slightly disagreeable odor, and may amount to as much as 
five quarts in twenty-four hours, and may number from twenty b 
thirty. Vomiting is thin and profuse; there are often cramps in 
the arms and legs, and a sensation of burning and pressure about 
the :enter of tb~ The patient becomes rapidly exhausted 

the loss : so much fluid from the blood, and the thirst is dic- 
ing. 

Collapse appears with ice cold feet, hands, and face, black lips, 
pinched features, stupor, feeble voice and weak, rapid pulse and 
breathing. This _r of collapse may last from rwo to twenty-four 



DISEASES OF ADULTS 557 

hours, and if recovery ensues the stage of reaction sets in with re- 
turning warmth to the skin, stronger pulse, more natural color, and 
increased amount of urine. Vomiting and diarrhea lessen. There 
is fever during the attack, as shown by the thermometer in the bowel. 
Relapses often occur after promise of recovery, which is, however, 
frequently complete within a week or two. 

The death rate varies from thirty to eighty per cent., according 
to the prevailing severity of the disease. Youth and old age are un- 
favorable conditions, as also pregnancy, early vomiting and diarrhea, 
and cold skin. 

Sometimes death occurs within two hours from the beginning of 
the attack without diarrhea; and occasionally, when the patient is 
apparently on the road to recovery, he becomes delirious with a 
rapid, weak pulse, and dies in an unconscious state. There are 
many very mild cases without collapse in cholera epidemics. 

Diagnosis. — Cholera morbus is the only disease likely to be con- 
founded with cholera. This is a common disease in hot weather in 
temperate portions of Europe and the United States, while cholera 
only appears at rare intervals at seaports where it is introduced by 
vessels from tropical countries. In severe poisoning by arsenic, cor- 
rosive sublimate and mushrooms, the symptoms resemble those of 
true cholera. 

The certain diagnosis of cholera depends upon the finding of the 
comma bacillus in the bowel discharges. 

Prevention.* — The patient must be isolated, and the discharges 
from the stomach and bowels must be received in vessels containing 
a five per cent, solution of carbolic acid, or ten per cent, solution of 
chlorid of lime, or in a mixture of freshly slaked lime (1 part) and 
water (4 parts). 

The patient should be washed about the mouth after vomit- 
ing and about the anus after each bowel movement. The bed and 
body clothes, napkins, towels, and handkerchiefs of the patient should 
be thrown into the carbolic solution, when soiled, and boiled for fif- 
teen minutes before again being used. Remnants of meals should be 
thrown into the fire, or into one of the solutions mentioned, and the 
eating utensils should be boiled for fifteen minutes after use. 



558 DIARRHEAL DISEASES— CONSTIPATION 

It is advisable for the attendant to wear some loose covering 
which can be slipped off before leaving the sickroom. The attendant 
should also wear rubber gloves when handling the patient. The 
gloves should then be boiled for fifteen minutes after being soiled. It 
is imperative that flies be kept from the sickroom. The bodies of 
persons dying of cholera should be wrapped in sheets wet with car- 
bolic acid solution, or other antiseptic, until burial. 

Healthy persons may avoid cholera during epidemics by drink- 
ing only boiled water, milk, and other fluids, and by avoiding impure 
ice, uncooked fruits or vegetables, and preventing the contamination 
of food with flies which convey the germs on their bodies. 

While cholera excites great anxiety on account of its fatality it is 
no more contagious than typhoid fever. There is no danger in being 
near a patient, as we have shown the germs are only in the vomitus 
and excrement and these must find their way into the mouth of a 
person in order that he may acquire the disease. The air is not in- 
fected by a patient. 

A blood serum from animals made immune to cholera has been 
injected into persons with great success in the way of prevention and 
also in lowering the death rate one-half. It is now the accepted 
special treatment in India and the Philippines. 

The attainment of general good health in a cholera epidemic is im- 
portant, and the occurrence of any diarrhea should demand im- 
mediate medical treatment. 

Treatment. — Diarrhea is usually the first symptom. The patient 
should at once go to bed and remain there, and a dose of three table- 
spoonfuls of castor oil should be given at once. The diet should con- 
sist of boiled milk, white of egg and water and whey, unless vomit- 
ing occurs, when all food should be withheld, but water may be given 
freely. Hot applications should be made to the belly, as poultices 
and hot cloths sprinkled with turpentine and covered with a hot water 
bag. A hot bath containing mustard, and hot water bags to the feet 
and legs are useful. 

For vomiting, lumps of pure ice may be held in the mouth and 
one-half a teaspoonful of brandy, in a tablespoonful of cracked ice, 
may be given every fifteen minutes to relieve thirst, strengthen the 



DISEASES 0¥ ADULTS 559 

patient, and stop vomiting; or, better still, tablespoonful doses of 
iced dry champagne may be used at the same intervals. The in- 
jection of morphin * (one-quarter grain) under the skin is most val- 
uable in relieving pain and other symptoms. If a physician is not ob- 
tainable one may use Squibb's cholera mixture 1 in teaspoonful doses, 
or paregoric 1 or laudanum, 1 as recommended for cholera morbus. 

Opium must never be used sufficiently to cause stupor, nor in 
the cold stage — when alcoholic stimulants, hot coffee and external 
heat are the best remedies. 

The injection into the bowel of a warm solution of tannic acid 
(one hundred and fifty grains to the quart), to the amount of two 
quarts, allowed to flow in slowly from a fountain syringe every 
three hours, is of great value in stopping the diarrhea. The patient 
should lie flat on his back, with the hips raised on a pillow. The in- 
jection of salt solution into the patient's vein can only be carried 
out by a doctor, but has proved of life-saving value in supplying 
water which is lost in vomiting and diarrhea. Muscular cramps are 
relieved by opium, rubbing, and warm mustard baths. 

During recovery the diet must be carefully watched, and should 
consist of thin gruels and boiled milk for several days. In no disease 
are the services of a physician more needed. The only object in de- 
scribing cholera in a book of this kind is that one may be given an in- 
telligent idea of the disease, which may be of use in prevention, and 
in case of an unfortunate emergency when a physician's aid could 
not be at once obtained. 

CONSTIPATION 

Constipation means the passing of an insufficient amount of excre- 
ment or feces. The movements may be infrequent, or small when 
passed at normal intervals. While the healthy person usually has one 
movement in twenty-four hours, some persons have naturally two or 
three movements daily, while others have but one movement in two 
or three days, and suffer no bad effects. 

Causation. — Constipation may be due to mechanical causes ob- 

1 These are all preparations of opium and can only be obtained with a 
doctor's prescription. 



560 DIARRHEAL DISEASES— COXSTIPATIOX 

structing the bowels, but this condition is comparatively rare. The 
more common causes are faulty diet and lack of exercise. We eat 
food which is too concentrated, as meat and eggs; and too much 
food is prepared and partially digested, as patent cereals and 
toast. We need a more bulky and coarse diet such as is taken by 
the peasantry of Europe. 

Women suffer more often than men, for various reasons. They 
eat, drink, and exercise too little; they wear tight clothes about the 
bowels ; they repress the calls of nature from shame or inconvenience 
in youth ; and their abdominal muscles are weakened by pregnancy in 
later life. Men form irregular habits through travel. One of the 
chief harmful results of habitual constipation is the resort to im- 
proper medicinal purgatives which increases the trouble by causing 
the bowels to rely upon a strong and unnatural stimulus to move them. 
Lack of tone in the muscles of the bowels is the common immediate 
cause in chronic constipation and is a symptom of general debility 
and nervous exhaustion. 

Constipation may be but a symptom of many other diseases, as of 
the stomach, intestines, female sexual organs, and disorders of the 
brain, lungs, and liver. It may be mechanical from pressure of 
tumors and from adhesions and kinks in the bowels. The condition 
which has been previously described (enteroptosis), where the stom- 
ach and bowels are dropped down out of place, leads to kinking of the 
large bowel and is a common cause of constipation, particularly in 
women. The use of the x-ray in picturing for us the shape and posi- 
tion of the stomach and bowels has been an enormous step in diagno- 
sis, and now no case of chronic constipation, which does not yield 
readily to treatment, should fail to have the benefit of x-ray exami- 
nation. 

In certain nervous disorders, as nervous prostration associated 
with diseases of the sexual organs and hysteria in women, and in 
old persons, there is a condition of contraction of the lower end of 
the bowel so that the passages are small and sausage-like, or consist 
of round, hard balls. The contraction in the lower bowel causes 
dilatation and gas in the upper part of the bowel. 

Constipation occurs more commonly in dark than in fair persons. 



DISEASES OE ADULTS 5G1 

Worry and anxiety are frequent causes of constipation by enfeebling 
the nervous mechanism which controls the action of the bowels. In 
most cases there is merely a sluggishness of the intestines due to lack 
of tone, particularly of the muscle of the lower bowel (colon) which 
propels the feces into the outlet, and the general causes we have 
to remedy are improper diet, insufficient exercise, and irregularity 
in going to the closet. 

Symptoms.' — In many persons constipation existing for a week 
will produce no symptoms, whereas in others absence of one daily 
movement will cause disturbance in health. Headache, dullness, 
a bad taste in the mouth, a coated tongue, a feeling of fullness or 
pain in the stomach or about the navel, nausea, and belching of wind, 
are some of the common symptoms of constipation. Mental depres- 
sion and dizziness are not infrequent. Attacks of vomiting some- 
times occur. 

In chronic constipation due to kinks in the bowel the patient be- 
comes much emaciated, has nervous symptoms and insomnia, and 
the skin assumes a brownish hue. Much of the so-called biliousness 
is nothing but the effect of constipation. It is perfectly possible to 
have a daily movement and yet some of the fecal contents be delayed a 
long time in pouches in the bowels. 

Diarrhea is caused by irritation produced by retained feces, 
which may become channeled, so that some escapes while retention 
still persists. Alternating constipation, diarrhea, and vomiting in 
women suggest retention of intestinal contents which may be felt 
by the physician in examining the abdomen. 

Muddy skin, pimples, and anemia form a common condition in 
girls owing to constipation. Constipation may also occasion pain in 
the back and a fullness or pressure low down in the abdomen in 
women during menstruation. Long-continued constipation is pro- 
ductive of piles. It is very probable that many nervous symptoms 
attributed to constipation, as neuralgia and dizziness, are in real- 
ity a cause of constipation and not a result. We have noted that 
in nervous disorders the nervous stimuli to the bowels may be de- 
ficient. 

Treatment. — Diet. — The treatment of constipation by diet is sue- 



562 DIAKRHEAL DISEASES— CONSTIPATION 

cessful in the vast majority of cases. The feeding of bulky food 
is generally necessary, although there are some persons who have 
constipation from eating too much and taking too little exercise, and 
these people are well when exercising regnlarly. 

Fish, meats, eggs, cheese, spaghetti, macaroni, milk, and toast are 
constipating because they leave little residue in the bowels. Soups 
are not of service because they are filling but not laxative. Six 
glasses of water should be taken during each twenty-four hours, and 
one glass of hot or cold water with a pinch of salt should be taken on 
rising. 

Of most importance in overcoming constipation are coarse bread — 
rye, whole wheat and Graham — fruits — prunes, peaches, pears, ap- 
ples, grapes, oranges, grape-fruit — and certain vegetables having a 
laxative action — tomatoes, cucumbers, potatoes, carrots, beets, onions 
and spinach. Then the coarser vegetables leaving most residue are of 
value, including corn, cabbage, Brussels sprouts, turnips, beans, 
squash, oysterplant, eggplant, celery, and peas. Acids are laxative, 
as found in fruit, pickles, buttermilk, salads with vinegar, cider, and 
acid wines. Fats are laxative, as bacon, butter, oil in salads, and 
cream. A suitable combination of the preceding forms the proper 
diet for constipation. It is easy to make unsuitable combinations 
which may produce distress and it is possible that an excess of acid 
may cause heartburn, and the coarser vegetables may induce flatu- 
lence. The taking of a little magnesia after meals will relieve heart- 
burn, and it may be best to avoid cabbage, baked beans, turnips, and 
Brussels sprouts in case the digestion is poor. 

We may suggest the following as a diet for constipation : 

Diet for Constipation 

Breakfast. — Old-fashioned oatmeal or cracked wheat or Graham 
meal, for cereal; 2 or 3 slices of whole wheat, rye, or coarse Graham 
bread, with butter; bacon; marmalade, honey, stewed prunes, or apple 
sauce; coffee and cream. 

Between Meals. — A glass of buttermilk in the middle of the 
morning. 

Lunch. — Fresh fish — sardines or smoked fish in moderate amount; 
fruit; 2 vegetables; salad; 2 or 3 slices of coarse bread and butter. 



DISEASES OF ADULTS 563 

Between Meals. — A glass of buttermilk in the middle of the 
afternoon. 

Dinner. — Vegetable soup ; a small amount of meat or fish ; 2 vege- 
tables; 2 or 3 slices of coarse bread and butter; salad," and fruit with 
dessert. 

Before Eetiring. — A glass of buttermilk. 

The essential articles are six or more slices of coarse bread and 
butter, with fruit at each meal ; salad and French dressing with two 
vegetables, including potatoes, at lunch and dinner ; and three glasses 
of buttermilk. In some patients the foregoing diet will cause too 
much flatulence so that other means, as agar and bran, or liquid al- 
bolene, may be tried. 

When it is impossible for a person to regulate his diet, as when 
boarding, he may find that eating six slices of coarse bread daily, 
with three glasses of buttermilk, may be sufficient, or the writer has 
found the following a most efficient combination : two or three table- 
spoonfuls of a mixture of equal parts of bran and agar-agar. This 
should be moistened with hot water, seasoned with salt, and eaten 
raw with sugar for breakfast. The diet may be otherwise such as 
has been ordinarily taken. 

If the bran and agar are eaten daily there are usually large, 
well-formed movements. The bran should be sterilized and kept by 
grocers in sealed packages (Ralston's). Agar-agar is a product of 
Japanese seaweed which should be bought in the apothecary in one- 
half inch lengths. It swells and forms bulk in the bowel, but is 
not absorbed, while the bran stimulates the intestines. The combina- 
tion is a harmless remedy which may be taken indefinitely. When 
the agar is insufficient it may be combined with the use of albolene. 
One tablespoonful one-half hour before meals three times daily (See 
below). Tea, cocoa and chocolate are constipating and are unsuit- 
able in constipation. 

Drugs and Injections. — Drugs should be used only when dietetic 
means fail, or when traveling, or when one is unable to secure a 
suitable diet. It is unwise for the young to begin the use of ca- 
thartics, but often adults take them for years without the slightest 
harm. The injury is negligible so long as the proper kind of cathartic 



564 DIARRHEAL DISEASES— CONSTIPATION 

— one which will not lead to greater constipation or require increase 
in the dose — is employed. Thus one may take one or two tablespoon- 
fuls of olive oil after each meal, beginning with a teaspoonful and 
gradually increasing. Recently liquid albolene (purified liquid vase- 
lin) has been used with good effect. One tablespoonful to one-half 
a tumblerful may be taken at bedtime without unpleasantness. This 
is absolutely harmless and acts as a lubricant, since it is not ab- 
sorbed. A tablespoonful may be taken three or four times daily 
between meals and at bedtime. 

Stewing an ounce of senna leaves, enclosed in a muslin bag, with 
four dozen prunes, makes an excellent remedy for constipation. A 
small saucerful may be taken two or three times daily for several 
weeks. Aromatic fluidextract of cascara sagrada, in doses of one-half 
teaspoonful — more or less — at bedtime, may often be taken continu- 
ously without increasing the dose, and in some cases the habit of regu- 
lar evacuation will become so established that the drug may be 
stopped altogether. Small doses of salts, as Glauber's, Epsom, Ro- 
chelle and Carlsbad salts, are commonly taken in amounts varying 
from a pinch to one or two teaspoonfuls in a whole glass of water 
on arising. It is rare that they can be taken continuously with- 
out increasing the dose or causing gas and distress in the bowels. 
They are not advisable in thin or pale persons. The same remarks 
apply to the use of such mineral waters as Pluto, Hunyadi Janos, 
Apenta, Congress, Carlsbad, Friedrichshall, etc. 

Aloes may be taken daily in the form of the compound laxative 
pill, one each night. One or more teaspoonfuls of sulphur, in milk 
or molasses, may be taken each night to produce a soft movement in 
persons troubled with piles. The daily injection of one pint of soap- 
suds with a fountain syringe, the patient lying on his back, is useful 
to secure a movement, but has no curative effect- The giving of 
large amounts of water by enemata, so as to wash out the lower 
bowel, is not advisable, except occasionally, as they tend to dilate 
and weaken the bowels in time. 

Habit. — Every person should have some regular hour each day 
for moving the bowels, whether there is any desire to do so or not. 
The muscles have more effect in moving the bowels if one bends over 



DISEASES OF INFANTS AND CHILDREN 565 

with the back parallel with the floor. Ordinarily in beginning treat- 
ment for chronic constipation the patient need not feel disturbed if 
the bowels do not move for several days. The bowels will undoubt- 
edly move within three or four days, and it is much better to wait 
than to rely upon a cathartic, unless symptoms urgently demand one. 
Violent straining is unwise ; after attempting for three to five minutes 
to move the bowels it is wiser to wait until the same time the next day. 

Physical Exercise. — Exercise, next to diet, is the most valuable 
means of overcoming constipation. Walking is hardly sufficient, but 
swimming, rowing, tennis, baseball, and, for persons at or past middle 
age, golf may be regarded as most suitable. The rowing machine, 
parallel bars, jumping horse, and pulleys are the most effective of 
gymnasium apparatus. Various exercises may be done at home, such 
as bending the body until the fingertips touch the floor, to the front 
and sideways, and taking the first position with the hands held above 
the head. Lying on the back on the floor and raising the stiffened 
limbs held together in a straight line until they are at a right angle 
with the body should also be given a trial. This should be re- 
peated for five minutes and then the movement should be reversed 
by raising the body at right angles with the legs, while the legs 
are held stiffly on the floor. This is very difficult unless the toes are 
held down by some object, as a bureau. 

Rubbing and kneading the belly with the fists for ten minutes 
each morning is of value. Rolling a five to seven pound cannon 
ball, covered with flannel, over the abdomen for five minutes each 
morning may bring about a cure. Electricity is of little value. 

DISEASES OF INFANTS AND CHILDREN 

DIARRHEAL DISEASES— SIMPLE DIARRHEA OR ACUTE INTESTINAL 

INDIGESTION 

Both the milder and the more severe form differ from summer 
diarrhea, or ileocolitis, in that there is an indigestion but not an actual 
inflammation of the intestines, from which recovery must be slow. 

Some diarrhea is commonly caused by overfeeding or improper 
feeding, or by any trouble weakening digestion, as teething. It may 



566 DIARRHEAL DISEASES— CONSTIPATION 

occur in children of all ages. It is of much importance, for the reason 
that the more serious forms of diarrhea often begin with the simple 
variety, and after the child is weakened, germs of the more dangerous 
forms may find a foothold. Therefore, it is exceedingly unwise to 
neglect diarrhea in an infant, particularly in hot weather. The im- 
proper food causing the intestinal indigestion irritates the bowels and 
thus provokes rapid expulsion of their contents. Other causes, noted 
under the consideration of diarrhea in adults, may sometimes lead to 
an attack of diarrhea in children. 

Symptoms. — The trouble begins with restlessness, and sometimes 
crying and fretting, owing to pain due to gases in the bowels. The 
discharges become frequent and loose, but without slime or blood, nor 
do they have the appearance of water, seen in cholera infantum. 
The passages may be greenish, but this is not of serious import and 
may only mean escape of bile. Fever is moderate or slight, although 
thirst may be excessive from loss of water in the numerous bowel 
movements. 

Or the indigestion may be much more acute and come on suddenly 
with high fever (104°-105° F.), vomiting, and colic, and the bowel 
movements frequent, with curds and undigested food in them. The 
discharges grow thinner and greenish in color, and may contain mucus 
but not blood. Recovery from this severe form may occur within a 
few days or it may turn into a genuine inflammation of the inner 
coat described under Summer Diarrhea. 

Treatment. — Nothing but cool, boiled water should be allowed 
for twenty-four hours ; liquid and solid food of all kinds is to be abso- 
lutely withheld. A teaspoonful of castor oil should be given as soon 
as possible to infants, and repeated if the trouble does not improve 
rapidly. When the oil is vomited at once tablets each containing one- 
quarter of a grain of calomel should be given, and one of these every 
two hours until eight have been taken. 

If there is much pain, ten drops of paregoric * on a little sugar 
may be given to an infant. The best remedy to employ, as long as 
the diarrhea lasts, is a saltspoonful of bismuth subcarbonate mixed 
with a little sweetened water and dropped on the tongue every three 

1 Paregoric (opium) can be bought only with a doctor's prescription. 



DISEASES OF INFANTS AND CHILDREN 567 

hours during the day. The food should be the same as that recom- 
mended under Summer Diarrhea. 



SUMMER DIARRHEA OF INFANTS 

(Ileocolitis) 

In this form of diarrhea there is actual inflammation of the 
mucous membrane covering the inside of the bowels, so that it is a 
much more serious and persistent disease than simple disturbance of 
intestinal digestion with diarrhea, described above. The name, ileo- 
colitis, means an inflammation of the lower. part of the small intes- 
tines (ileum), and of the large intestines (colon) which terminate 
at the anus, or outlet of the bowels. 

This diarrhea is due to an infection with germs which are prob- 
ably chiefly introduced in milk which has become contaminated in the 
barn with manure and dirt, or by impure water, flies, and human 
fingers during its many handlings. This disease is probably the most 
common, and is the cause of more deaths than all the other diseases of 
infancy combined. It occurs during hot weather, and almost exclu- 
sively in babies who are artificially fed, as only three per cent, of 
cases are found in the breast fed (Holt). 

The same group of germs or dysentery bacilli found in adult 
dysentery are also present in summer diarrhea. They are not always 
introduced through feeding of dirty milk, as they are sometimes 
found in diarrhea in breast-fed babies and may be conveyed by drink- 
ing water. But two forms of bacteria, or germs, are present in the 
bowels of healthy, milk-fed infants, a germ causing souring of milk 
in the upper bowels, and that always found in the lower bowels of both 
babies and infants (colon bacillus). Under certain circumstances, 
as in hot weather, these germs — together with the dysentery germs 
and some others — unite to produce diarrhea in children. 

Prevention. — Prevention must be the important consideration 
in this disease. The proper pasteurization of milk, whether it be 
certified or not, will largely prevent this disease. Pasteurization is 
advisable all the year round, but milk used for feeding children from 
June to October should certainly be pasteurized. The water used by 



568 DIARRHEAL DISEASES— CONSTIPATION 

babies for drinking purposes should always be boiled during these 
same months. These are the essential features in prevention of sum- 
mer diarrhea, and at the same time, of infant mortality. The death 
rate of infants has been cut in two by improvement in the milk 
supply, as by Dr. Goler, in Rochester, New York. 

The avoidance of heat by change of residence; light clothing, 
as a flannel binder and thin dress ; fresh air, as obtained by keeping 
the baby outdoors day and night ; and cleanliness and boiling of the 
nipples, bottles, and milk utensils daily, are also necessary means of 
prevention. Of course the breast feeding of babies is the most im- 
portant, but the principal danger is during the first summer follow- 
ing weaning. By using boiled or properly pasteurized milk the dis- 
ease can practically always be prevented. 

Symptoms. — Mild cases may develop slowly, as simple diarrhea 
from intestinal indigestion (already described), with an increasing 
number of bowel discharges, of a brownish, yellowish, grayish, or 
greenish color, containing curds of milk or other undigested food. In 
other cases the diarrhea may begin suddenly with loss of appetite, 
fever, thirst, crying, colic, and vomiting. The baby may either be 
listless, restless, or sleepy, or convulsions may occur. The bowels 
are often distended by gas, with frothy discharges, having an unusu-. 
ally offensive odor. The poisons, produced by germs growing in the 
contents of the bowels, lead to inflammation of the lining mucous 
membrane, with the formation of mucus (as in cold in the head), pus, 
and in severe cases to destruction of the tissues and blood vessels of 
the intestines (ulceration), so that the discharges contain blood, as 
well as mucus and pus. The number of discharges varies greatly, 
from two or three to twenty-four daily. The skin is apt to become 
raw about the exit of the bowel (anus) from the irritation of the 
frequent discharges. 

Loss of weight is soon apparent, first by softness and flabbiness of 
the flesh, and then by emaciation. When much mucus and pus occur 
in the discharges, several weeks of careful treatment are necessary 
before recovery ensues. The disease may become chronic with passing 
of fever and pain, and persistence of loose passages and mucus, with 
loss of weight. Nervous symptoms are common, as stiffness and con- 



DISEASES OF INFANTS AND CHILDREN 569 

tractions of the arms and legs. The disease may drag along for 
months, and recovery or death may ensue. 

When great straining and pain attend the bowel movements, which 
are sometimes almost continuous, the inflammation attacks chiefly the 
lower bowel. This is a true dysentery. The passages are bloody and 
slimy and small in amount, and the constant straining leads to pro- 
trusion of the bowel. 

If the discharges become less frequent, the slime and blood dimin- 
ish, and the expression assumes a brighter appearance, the chances 
of recovery within a week are good ; but if the face is pale and 
anxious, the vomiting continues, the bowel movements remain fre- 
quent and the belly is swollen, painful, and tender, and restlessness, 
moaning, and convulsions are present, with little or no urine passed, 
the outlook is indeed bad. 

Treatment. — For treatment of this condition see under Cholera 
Infantum. 

CHOLERA INFANTUM 

(Acute Milk Infection) 

This very fatal, but comparatively rare form of diarrhea, is seen 
almost exclusively in bottle-fed infants. It is a rapid, violent form 
of poisoning by germs usually derived from impure cows' milk. 

Symptoms. — Cholera infantum comes on suddenly in hot weather, 
with constant vomiting and diarrhea. The face becomes very pale, 
the eyes sunken, and the features pinched and expressive of alarm and 
suffering. The skin is often cold and clammy, but if the thermometer 
is placed in the bowel, it shows a very high temperature (102° to 
107° F.). The pulse is rapid and weak, the breathing shallow and 
hurried. The passages, at first of a somewhat normal color and con- 
taining curds, become rapidly looser and paler, and finally only 
copious watery discharges escape from the bowels. Fluid is thus 
drained away from the blood, for there are often as many as thirty 
discharges in the twenty-four hours. Vomiting is constant and aggra- 
vated by food or drink. 

The baby wastes away from fretfulness and restlessness, becoming 
dull, stupid, and finally unconscious with the head 1 thrown back, eyes 



570 DIARRHEAL DISEASES— CONSTIPATION 

half open, lips apart, and fingers clutched ; there may be convulsions. 
The child may remain in this condition for two or three days. The 
diarrhea and vomiting may stop, but the child may die in uncon- 
sciousness. The course may be very rapid, and death may occur 
within a few hours. A marked improvement or fatal outcome may 
be expected within two or three days. 

Cholera infantum may be distinguished from other forms of in- 
fantile diarrhea by the suddenness and violence of the attack, with 
constant vomiting, large watery bowel discharges, great weakness and 
collapse, and high fever. The outlook is bad. 

Treatment of Summer Diarrhea and Cholera Infantum. — The 
treatment of these disorders must be prompt and heroic. No precon- 
ceived ideas or foolish sentiment for the suffering baby, on the parent's 
part, should be permitted to intervene, or a fatal result may follow. 
Interference from well-meaning but misguided relatives, neighbors, 
and friends, thought to be wise in the management of children, is 
particularly common, and as frequently defeats in the most com- 
plete manner all the doctor's efforts. Especially do these kindly but 
officious persons think the treatment too harsh and urge special or 
patent foods. 

The essence of treatment consists in ridding the stomach and 
bowels of the offending poison and then in giving these organs abso- 
lute rest for a time by total abstinence from all food. One or two 
teaspoonfuls of castor oil or one-quarter grain tablets of calomel, 
given hourly until one or two grains are taken, should be the rule as 
the first form of treatment. The oil is the better unless vomiting 
prevents its retention. The immediate summoning of a doctor is most 
important, in severe cases of vomiting and diarrhea in infants, so 
that he may at once wash out the stomach and bowels, as this is by 
far the most rapid and effective way by which to get rid of the 
poison. 

When a doctor is not obtainable the baby's stomach may be 
cleansed by giving it tepid boiled water to drink to encourage vomit- 
ing, and washing out of the stomach. If the water is refused the 
child's nose may be held until the mouth is opened for air, when 
the water may be poured down. It is not cruel to enforce such treat- 



DISEASES OF INFANTS AND CHILDREN 571 

ment. The use of bowel injections is also of the greatest service. If 
the temperature is high (over 103° F.) cold salt water injections 
should be given several times a day : the injection of saline solution 
is always advisable. The proportion of common salt is one level 
teaspoonful to a pint of water. The baby should lie on his back, a 
little to the left side, with the hips raised on a pillow. Two or three 
quarts should be given from a fountain syringe raised two or three 
feet above the patient. In case the fever is not high the injection 
may be given warm. A pint should be allowed to flow in from a soft 
rubber tube (catheter) or, in its absence, from a hard rubber tip. 

After the pint has been expelled more should be injected until the 
two or three quarts are given. This should be repeated at least 
twice daily if it appears beneficial. The water washes out the poisons 
in the bowels and some is absorbed and takes the place of that lost 
by diarrhea. 

All water given the baby by mouth or bowel during the entire sick- 
ness should be boiled. Later in the disease, with slime and blood in 
the movements showing ulceration in the bowel, alum may be used 
to the amount of one teaspoonful to a quart of water, or silver ni- 
trate — fifteen grains to a quart. 

The medicinal treatment consists in giving a saltspoonful of bis- 
muth subcarbonate mixed with water, four times daily. This should 
not be begun, however, until the bowels have been well cleared out 
and the fever is reduced. Sponging the baby from head to foot 
several times daily with slightly cool water is useful in fever. The 
baby should remain outdoors day and night, if possible, in hot weather. 
Kemoval to seashore or mountain often does much good. The bismuth 
should be continued as long as the diarrhea lasts, although it colors 
the passages black. Twenty drops of whisky or brandy in a tea- 
spoonful of water may be given hourly when there is weakness. 

If there is much pain it may be relieved by giving ten drops of 
paregoric x to a one year old baby, repeating it once in three hours if 
necessary. With high fever and bad smelling passages this should 
not be used, as paregoric is a form of opium and causes constipation. 
The feeding is of the utmost importance. 

1 Paregoric ( opium ) can be bought only with a doctor's prescription. 



572 DIARRHEAL DISEASES— CONSTIPATION 

After twenty-four or forty-eight hours of starving (giving only, 
boiled water) either broths, beef juice, egg water, or barley water 
may be used. Milk is wholly unfit as a food in these cases and should 
not be resumed until diarrhea is passed, or late in convalescence. 
When the discharges are very bad smelling, barley water is the best 
food ; when the passages are frothy and acid (as shown by turning 
blue litmus paper red), broths, egg water and beef juice are pref- 
erable. Otherwise the baby should be given the food among these 
articles for which he has a preference. 

Egg Water. — Egg water is made by stirring the whites of three 
eggs into a pint of cold boiled water and flavoring with salt. 

Meat Broths. — Broths of beef, mutton, veal, or chicken are 
made by placing two pounds of cut meat (free from fat), with a cup- 
ful of cold water, in a glass jar on the ice for three hours and then 
slowly cooking it for three more hours, when it is allowed to cool, the 
fat skimmed off, and salt added. The juice squeezed from a rare 
piece of round of beef may be given occasionally in tea spoonful doses 
in the broth. 

Barley Water. — To make barley water, place two teaspoonfuls of 
patent barley in a pint of cold water; boil down to two-thirds of a 
pint, and strain. 

A few ounces of one of these — that is, egg water, or broth, or 
barley water — should be warmed and given in a bottle or spoon every 
two hours. 

This dietary must be continued until the acute diarrhea ceases, 
when pasteurized milk may be used, beginning with only one or two 
feedings daily and using skim milk diluted with an equal part of 
water ; sometimes it may be best to partially digest the milk by using 
peptogenic milk powder. Whey or buttermilk and some of the 
patent foods, as Malted Milk or Mellin's Food, may also be service- 
able during recovery from the disease. 

In children over three years of age the disease is generally curable 
by the use of a dose of castor oil (one to four teaspoonfuls), and, after 
the bowels have moved, by a diet of broth, boiled milk, and toast. 
If the diarrhea becomes chronic it may be necessary to feed milk 
properly diluted or digested, as recommended in this volume for 



DISEASES OF INFANTS AND CHILDREN 573 

infants with delicate digestion. Of course such cases should be 
under the care of a physician, as they need the most careful watch- 
ing for a long time. 

Unless suffering from that most violent form of milk poisoning, 
cholera infantum, a baby will usually recover from summer diarrhea 
if the treatment herein outlined is conscientiously and persistently 
followed and hysterical excitement and advice from would-be helpers 
be avoided. 

Infants show wonderful powers of recuperation, although a sick 
baby produces a greater upheaval in the family than illness of all 
the other members of the family put together. 

CONSTIPATION IN INFANTS AND CHILDREN 

Constipation is a very common disorder in infants and more often 
in those artificially fed. Water should be given infants two or three 
times daily in addition to that contained in their milk. The infant's 
bowels should move twice daily and the passages should be of a 
bright yellow color and of a soft pasty consistence, without lumps or 
curds. 

Treatment. — Constipation in bottle-fed babies is the rule and 
must be endured. The golden-yellow passages of the normal breast- 
fed baby are not to be expected in the bottle-fed baby. The best we 
can hope for usually is a brownish-yellow passage, and it is often 
whitish or clay-colored. Sometimes with a change of diet in bottle- 
fed babies, as the addition of cereal, constipation will disappear and 
the movements become much more normal. When a baby is overfed 
there may be constipation with dry, pale feces. 

One of the best remedies to combat constipation in babies is 
Phillip's milk of magnesia, one teaspoonful in a nursing bottle daily. 
A teaspoonful of orange juice or the juice of stewed prunes, given 
three times daily between feedings, may aid in securing a normal 
movement. A teaspoonful of olive oil or paraffin oil night and 
morning may act as a harmless laxative. Cream is often advised but 
more frequently increases constipation. 

When milk is too rich the passages often are quite white and look 
as if they contained curds; but this appearance is due to a kind of 



574 DIARRHEAL DISEASES— CONSTIPATION 

soap formed from the excess of fat in the bowels which is not di- 
gested and absorbed. Constipation may be relieved by the injection 
into the bowel each night of one-half cupful of water from a soft 
rubber bulb syringe with a soft rubber tip. A fresh bulbful should 
be injected as soon as the previous one has escaped, until a good move- 
ment occurs. When magnesia added to the milk is not effective, one 
may use an enema. Constipation may also be relieved by the daily 
introduction into the bowel, after wetting, of a small, conical piece 
of Castile soap — about as thick as a leadpencil and three-quarters of 
an inch long; or the gluten suppositories, sold by druggists for ba- 
bies, may be used. 

As soon as a baby is two months old a regular time for the bowel 
movements should be arranged. The baby should be placed upon a 
small vessel at a regular time after its morning and evening meal. 
Its back may rest against the nurse who will also support its body in 
front. It may be necessary to start the habit by the use of a soap 
suppository, but after a little while this must be dispensed with. 
Within a few weeks the baby will have a movement soon after he is 
placed on the vessel. One should indeed be glad to find constipation 
in a bottle-fed baby in place of possible diarrhea. The constipation 
will gradually disappear with the beginning of a general diet. 

Older children should be treated for constipation, as are adults, 
by regulating the diet, as recommended, and giving stewed prunes, 
apple sauce, or baked apple at each meal. 



CHAPTER V 

DISORDERS OF NUTRITION 

Diabetes. Obesity. Beriberi. Scurvy. Pellagra. Gout and Goutiness. 

DIABETES 

Diabetes consists of a group of symptoms, including thirst, the 
passage of a large amount of urine, and loss of weight, caused by dis- 
turbance in the assimilative processes of starches and sugar, and due 
to the presence of large amounts of sugar in the blood. 

Diabetes is not at all a disease of the kidneys, as seems to be 
the popular impression. In health starchy food and sugar are con- 
verted, in the upper part of the intestines, by the action of the diges- 
tive ferments, into grape sugar, and this is carried into the liver as 
such, because all the blood streams through this organ from the 
bowels. 

The liver is the great factory and warehouse of sugar. Factory, 
because it transforms grape sugar (glucose) into a new substance, 
called glycogen ; and warehouse, since sugar is capable of being stored 
in this form in the liver. The same process goes on to a less extent 
in the muscles — i. e., some of the sugar is stored there as glycogen. 

The maximum storage of sugar in the human body amounts to 
about ten ounces. Glycogen, in its combustion in the liver and 
muscles, is the fuel which supplies heat and energy to the body and is 
therefore a large source of muscular work. Starches, as repre- 
sented by bread, potatoes, and cereals, together with sugar, normally 
supply about half the bodily requirements for food and energy. In 
the absence of such food, meats, fish, and fats, and the same nutrients 
among vegetables, may replace the starches and sugars, as they do 
in the treatment of diabetes. 

575 



576 DISORDERS OF NUTRITION 

In normal individuals there is but the most minute amount of 
sugar circulating in the blood — from 1 to 1.5 grains to the quart. In 
diabetes there may be one hundred times this quantity. The grape 
sugar coming to the liver in diabetes, instead of being stored there 
as glycogen, sweeps through the organ and passes into the blood (as 
grape sugar) and is not assimilated as such by the body, but ab- 
stracts from the system a large amount of water, for the solution of 
the sugar, and escapes unchanged in the urine. In this way thirst 
and great increase in urine may be explained. Also the body often 
wastes away, from loss of assimilation of the starches and sugar, 
and the appetite is frequently enormous in nature's attempt at com- 
pensation. 

But the function of the liver, in converting sugar into glycogen 
and storing it as such, is subject to the influence of many outside 
organs. In fact there is an interlocking group of organs controlled 
by the nervous (sympathetic) system, with headquarters in the brain 
(floor of the fourth ventricle), which has complete mastery over 

i 

the sugar output of the liver. One set of influences increases the 
action of the liver in its power to store sugar as glycogen and keep 
it from escaping into the blood. 

The other set of influences produces the contrary effect, and 
prevents the liver from storing glycogen, but allows of free passage 
of sugar into the blood and urine, and favors diabetes. The effect of 
the nervous system is seen in the influence of worry, shock, strain, 
and excitement in favoring diabetes. The influences of the other 
organs are due to internal secretions which pass into the blood and 
act on the liver directly, or on other organs affecting the liver — to 
increase or prevent the storing of sugar in the liver. Thus certain 
small glands adjoining the kidneys (adrenals), through which the 
nervous path controlling sugar storage passes (left adrenal) to the 
liver, secrete a substance which tends to prevent the storing of sugar 
in the liver. An excess of secretion of these glands will cause 
diabetes. 

Then another large gland, the pancreas (situated behind the 
stomach), through its internal secretion, acts to increase the liver's 
power to store sugar and to prevent diabetes. But there are three 



DIABETES 577 

other glands whose secretions act in their turn on the pancreas. Two 
of them, the thyroid (in the neck) and the pituitary (at the base of 
the brain), tend to set aside the action of the pancreas and so, if their 
secretions are morbidly excessive, the result may be diabetes. The 
secretion of the third gland (parathyroids — under the thyroid gland) 
strengthens the action of the pancreas in causing the liver to store 
sugar as glycogen. 

The chief cause of diabetes is disease and loss of function of the 
pancreas. 

In order to properly treat diabetes it is important to be able 
to determine in which part of the mechanism the trouble is sit- 
uated and then be able to remedy the fault at its origin. Our 
knowledge is not sufficient for this at present. By eliminating 
starches and sugars from the diet, and allowing proteids and fats to 
take their place, we may largely remove the sugar-forming function 
altogether. Some sugar may, however, be formed from fat and 
proteids and, in severe cases of diabetes, the liver may not be able to 
even keep this sugar out of the blood and urine. 

Causes. — The assimilation of an excessive amount of starch and 
sugar in a normal person may lead to a temporary excretion of sugar 
in the urine — through failure of the liver to store it — but it is a 
curious fact that disease of the liver itself does not cause diabetes. 
Heredity is important in diabetes, often being found in several 
members of the family and in their descendants. Diabetes is closely 
allied to obesity and gout in that it is more frequent in subjects of 
these disorders or their offspring. The disease is more common in 
adults and in men. It is very fatal in children where the disease 
is more often hereditary. The well-to-do and Hebrews are the chief 
sufferers— the two classes are indeed often synonymous. 

Symptoms. — Excessive thirst and the frequent passage of large 
amounts of urine are the most salient symptoms. Both the thirst 
and the large quantity of urine secreted are directly due to the 
excessive amount of sugar in the blood which requires so much water 
for its solution. 

The urine is pale and has a sweet taste and odor, and from two 
to seventeen quarts may be passed in the twenty-four hours. The 



578 DISORDERS OF NUTRITION 

amount which should be passed in health is three pints in this time. 
The greater quantity is passed during the day in diabetes, which 
differs from the case of B right's disease, in which there is an in- 
creased secretion of urine chiefly during the night. In many cases of 
diabetes the symptoms are so slight that discovery of the disease can 
only be made by a routine examination of the urine of all patients for 
sugar. This is the rule among all careful physicians and is one of 
the requirements for formal examinations of persons for life insur- 
ance, etc. 

Itching of the skin, together with loss of weight, notwithstanding 
an enormous appetite in many cases, are also suggestive of diabetes. 

Pain in the small of the back, dry skin, boils, eczema, gangrene, 
cataract, and increasing near-sightedness in adults, are among the 
frequent complications of diabetes. The treatment comprises the 
use of proteid (meats, fish, eggs, etc.) and fats in place of the sugars 
and starches. 

While the proteids are burned up thoroughly it often happens 
that the fats undergo incomplete combustion, and the resulting 
fatty acids poison the patient. This is the common cause of death 
in diabetes and occurs in unconsciousness or coma. Coma may 
begin in various ways, as great difficulty in breathing, or with a 
condition resembling alcoholic intoxication with headache, abdom- 
inal pain, pain in the limbs, drowsiness, or again with a faint feeling 
after exertion. When a person is found in a state of unconsciousness, 
with dilated pupils, a fruity or winelike odor in the breath and 
with long-drawn, strong inspirations, and short, slightly sighing 
expirations, diabetes should always be suggested. 

Coma may appear suddenly in diabetics owing to injury, shock, 
surgical operation, an attack of indigestion or alcoholic excess. 

Course and Outlook.' — In children the course is apt to be rapid 
and fatal, especially in those with a diabetic inheritance. In persons 
over fifty, particularly if stout and active, and given to worry, over- 
work, and excesses in eating and drinking, the outlook is very good 
if the patient leads a normal life and restricts himself to a proper 
diet. In such persons the life may not be shortened by diabetes. 

In thin individuals the disease is apt to be more severe. If the 



DIABETES 579 

sugar disappears from the urine, on removing all starches and sugars 
from the diet, and the patient can stand a certain amount of starch — 
as a baked potato or a slice or two of bread daily — without leading 
to escape of sugar in the urine, the case is again very favorable. 
The unpleasant symptoms usually subside with the disappearance of 
sugar from the urine. 

Prevention. — Prevention applies especially to the children of 
diabetic parents; these should be brought up on a diet from which 
candy, cake, and sweets generally are largely excluded. Testing the 
urine at least four times a year in the children of diabetics, also in 
patients and their children, and in those who have previously had 
sugar in the urine, is of the utmost importance. Since diabetes and 
obesity are apt to be associated, the stout and their children should 
reduce their weight by appropriate diet and exercise. 

Treatment.- — The treatment is chiefly dietetic by excluding 
starches and sugars from the food. The physician usually begins by 
starving the patient for one to three days, until all sugar has dis- 
appeared from the urine, and then he gradually allows the patient 
to take starch in the form of bread (55 per cent.) or potatoes (16 to 
24 per cent.) until sugar again appears in the urine. This shows the 
tolerance of the patient. Then the patient may be permitted to take 
daily about one-half of that amount of starch which will lead to the 
presence of sugar in the urine. Sugar should be wholly withheld. 
If a patient is losing weight by excluding starchy food he must be 
allowed a little, even though he gains in weight and some sugar is 
lost in the urine. 

The following diet is one in which starch and sugar are excluded 
and which may be taken by any person with diabetes as a test : — 

Test Diet for Diabetes 

Breakfast. — Coffee, large cup with two tablespoonfuls of cream, no 
sugar; 4 ounces of beefsteak, chop, or ham; and 1 or 2 eggs. 

Lunch. — Clear soup with one egg; steak or beef, 3 ounces; 1 slice of 
bacon. Salad with lettuce or celery, tomatoes or cucumbers and 
oil, vinegar, salt and pepper to taste. Dessert made from 1 egg and 
2 tablespoonfuls of cream. Coffee without sugar or cream. 



580 DISORDERS OF NUTRITION 

Afternoon Tea. — 1 cup of tea with 1 tablespoonful of cream, no sugar. 

Dinner. — Clear bouillon or other clear soups, 6 ounces; fish with but- 
ter, 4 ounces; beef or mutton, 4 ounces — or without fish, 8 ounces; 
butter 2!/2 drachms; lettuce salad with ten drachms of vinegar and 
5 drachms of oil; green vegetable, as below; cheese, 5 drachms; 
black coffee without sugar. 

In addition to above, diabetics may eat the following: — 

Additional Articles op Diet 

Meat — the muscle of beef, veal, mutton, game, poultry, tongue, heart, 
brain, marrow, sweetbread, gelatin and meat jellies. Fish of all kinds 
— caviar, cod-liver oil, clams, oysters, lobsters, crabs. Eggs (10 to 20 
per cent, fat), animal and vegetable fats, bacon, suet, olive oil, butter 
(8 per cent, fat) which should be used on meat, eggs, spinach and other 
vegetables. Rich cream (milk contains milk sugar), all cheese, espe- 
cially Swiss cheese. Vegetables — cress, tomatoes, cabbage, cauliflower, 
sprouts, artichokes, mushrooms, truffles, olives, onions, garlic, celery 
leaves, lettuce, cucumbers, and radishes. Fruits — only huckleberries, 
and young raspberries on account of sugar. Desserts — souffles of eggs, 
gelatin, and lemon. Tea and coffee, diabetic cocoa (Rademenn's) and 
von HoevePs saccharin chocolate, without sugar. 

In mild cases the following articles in the following quantity 
are allowed : 

Quantities Allowed in Mild Cases 

Beans and peas (1 drachm) ; wax beans, turnips, carrots and celery 
root (1 ounce) ; walnuts (6), hazel nuts (10), almonds (8), (no chest- 
nuts) ; oranges, lemons, plums, raspberries, strawberries, apples, pears, 
apricots, peaches, cherries in moderation; and milk or buttermilk, 1 
glass. 

Forbidden Foods 

Liver, sugar, candy, maple sugar or syrup, pies, pastry, cake, jelly, 
preserves, stewed fruits, ice creams, syrups and molasses, thick gravies 
or sauces or soup, hot cakes, cereals including hominy, macaroni, vermi- 
celli, breakfast foods, sago, tapioca, rice, dried beans, macaroni, sweet 
wines, ginger ale, sweet soft drinks, champagne and liqueurs. 

By Permission 
Whisky is allowable in moderate amount. Bread, crackers, and pota- 
toes are allowed by permission of a doctor, in specified amounts. 



DIABETES 581 

The patient with diabetes should take such a diet, as the above 
test diet, for some weeks, and variety may be secured by replacing 
articles in the test diet by others in the list which all diabetics may 
take. 

Xo patient should attempt to treat himself according to any 
book and the lists given are supplied for purposes of general infor- 
mation and convenience. The doctor will allow as much of the 
articles in the list for mild cases as the individual will tolerate. 

Bread and potatoes are the articles most missed, and the amount 
the patient can take will depend upon his personal condition, as 
determined by urinary examinations. Saccharin may be used in 
place of sugar — which the patient may not take again during his 
life. The dose of saccharin is one and one-half grains daily. Occa- 
sional treats of bread and potatoes are allowable, and absolute fasting 
in bed from Saturday night until Monday morning is often beneficial. 

There are various substitutes for common bread which contain 
somewhat less starch — as gluten, bran, aleuronat, and soya bread — 
but these are not very satisfactory generally, although bran and 
gluten bread are often palatable and may be eaten in large quantities. 

Diet in Seveee Cases 

In severe cases 8 ounces of well-cooked oatmeal, mixed with an equal 
weight of butter and the whites of 6 or 8 eggs, may be given as the sole 
diet in 4 meals in the twenty-four hours. Tea, coffee and a moderate 
amount of whisky may also be used as beverages in these cases. 

The hygiene of the diabetic's life is important. While he should 
lead a quiet, even life it is better, in most cases, that he work than 
wander about the world after health. Warm clothing and an 
equable climate are advisable. The use of daily warm baths and 
frequent changes of underclothing render the occurrence of boils 
and skin eruptions less probable. Sea bathing and cold baths are' 
inadvisable. 

Diabetics frequent the foreign spas but this is not desirable except 
in those who have mild cases and are suffering also from other 
conditions, as obesity and gout, which may be benefited by the treat- 
ment given at mineral springs. All excesses are to be avoided, espe- 



582 



DISOEDEES OF XUTEITIOX 



cially alcohol. Constipation is also most detrimental to diabetics. 
The test of susceptibility to diabetes consists in the appearance 
of sugar in the urine after taking three ounces of glucose. 

OBESITY 

To estimate the meaning of obesity a knowledge of the normal 
weight is necessary. In the table below is given the average weight 
of healthy men and women for different ages and heights. 

A simple rule of insurance companies is that a weight of over 
three pounds to the inch in height is excessive, while a weight under 
two pounds to the inch in height is below normal. 

TABLE OF HEIGHT AND AVERAGE WEIGHT AT VARYING AGES 

Based upon an Analysis of 74,162 accepted Male Applicants for Life Insurance, as 
reported to the Association of Life Insurance Medical Directors, 18.97. x 



Heights 


15 

to 
24 


25 
to 
29 


30 
to 
34 


35 

to 
39 


AGES 
40 

to 
44 


45 
to 
49 


50 
to 
54 


55 
to 
59 


60 
to 
64 


65 
to 
69 


5 ft 


in 


120 


125 


128 


131 


133 


134 


134 


134 


131 










n ft 


1 in 


122 


126 


129 


131 


134 


136 


136 


136 


134 










5 ft 


2 in 


124 


128 


131 


133 


136 


138 


138 


138 


137 










5 ft 


3 in 


127 


131 


134 


136 


139 


141 


141 


141 


140 


140 








5 ft 


4 in 


131 


135 


138 


140 


143 


144 


145 


145 


144 


143 








5 ft 


5 in 


134 


138 


141 


143 


146 


147 


149 


149 


148 


147 








5 ft 


6 in 


138 


142 


145 


147 


150 


151 


153 


153 


153 


151 








5 ft 


7 in 


142 


147 


150 


152 


155 


156 


158 


158 


158 


156 








5 ft 


8 in 


146 


151 


154 


157 


160 


161 


163 


163 


163 


162 








5 ft 


9 in 


150 


155 


159 


162 


165 


166 


167 


168 


168 


168 








5 ft. 


10 in 


154 


159 


164 


167 


170 


171 


172 


173 


174 


174 


5 ft 


11 in 


159 


164 


169 


173 


175 


177 


177 


178 


180 


180 








6 ft. 


in 


165 


170 


175 


179 


180 


183 


182 


183 


185 


185 


6 ft 


1 in 


no 


177 


181 


185 


186 


189 


188 


189 


189 


189 








6 ft 


2 in 


176 


184 ' 


188 


192 


194 


196 


194 


194 


192 


192 








6 ft 


3 in. . . 


181 


190 


195 


200 


203 


204 


201 


198 













1 Prudential Life Insurance Co. 



OBESITY 583 

TABLE SHOWING THE AVERAGE WEIGHT OF 58,855 INSURED WOMEN 1 



Heights 


15 
to 
19 


20 
to 
24 


25 
to 
29 


30 
to 
34 


AGES 

35 
to 
39 


40 
to 
44 


45 
to 
49 


50 
to 
54 


55 
to 
59 


60 
to 
64 


4 ft 


11 in... . 


111 


113 


115 


117 


119 


122 


125 


128 


128 


126 








5 ft. 


in 


113 


114 


117 


119 


122 


125 


128 


130 


131 


129 


5 ft. 


1 in 


115 


116 


118 


121 


124 


128 


131 


133 


134 


132 


fi ft. 


2 in 


117 


118 


120 


123 


127 


132 


134 


137 


137 


136 








5 ft 


3 in 


120 


122 


124 


127 


131 


135 


138 


141 


141 


140 








5 ft 


4 in. . . 


123 


125 


127 


130 


134 


138 


142 


145 


145 


144 








5 ft 


5 in 


125 


128 


131 


135 


139 


143 


147 


149 


149 


148 








5 ft 


6 in 


128 


132 


135 


139 


143 


146 


151 


153 


153 


152 








5 ft 


7 in. . . 


132 


135 


139 


143 


147 


150 


154 


157 


156 


155 








5 ft 


8 in 


136 


140 


143 


147 


151 


155 


158 


161 


161 


160 








5 ft 


9 in 


140 


144 


147 


151 


155 


159 


163 


166 


166 


165 








5 ft 


10 in 


144 


147 


151 


155 


159 


163 


167 


170 


170 


169 









1 Prudential Life Insurance Co. 

Weight is of importance in respect to age. Heavy weight in 
persons over forty is a decided disadvantage from a life insurance 
point of view, their death rate being much above the average. On 
the other hand individuals of light weight past middle age have as 
good an expectancy of life as those of normal weight. Young persons 
under weight, especially if there is a history of consumption in the 
family, have a mortality much above the average. In young persons, 
otherwise healthy and of good physique, overweight is not unfavor- 
able from the insurance viewpoint — unless the abdominal measure 
exceeds that of the chest, which is undesirable at all ages. Insurance 
statistics show that certain diseases, as heart disease, bronchitis, con- 
stipation, piles, diabetes, gout, stone in the kidney and Bright's 
disease of the kidney, occur more often in the stout after middle 
age. Hardening of the arteries and apoplexy are more frequent in 
the obese, and they have less resistance to surgical operation and 
acute diseases, as pneumonia and typhoid fever. For these reasons 
the insurance companies reject or handicap overweight individuals 



584 DISORDERS OF XUTRITIOX 

at or after middle age, unless there is a family history of obesity 
with longevity. 

Causes. — In a general way overeating and lack of exercise is 
responsible for much fatness. Heredity is important. The secre- 
tions of certain glands in the body are absorbed into the blood and 
increase or diminish the tendency to fat formation. Thus when 
either sex is castrated (removal of either the testicles or ovaries) 
the secretions of these glands are stopped and stoutness is apt to 
follow. The same result occurs at the change of life in women when 
the ovaries cease to secrete. Stoutness is seen in eunuchs and in 
women whose ovaries are removed in early life for disease. With 
partial removal (posterior lobe) or disease of the pituitary gland at 
the base of the brain there is great increase in weight. Giants are 
formed through disease of this gland. Great obesity in children is 
frequently due to disorder of the pituitary gland and is often asso- 
ciated with poor sexual development. 

On the other hand, an excess of secretion of the thyroid gland 
in the neck produces emaciation {See Goiter) and the dried sheep's 
gland is sometimes given to reduce obesity in man. 

Symptoms. — The physical inconvenience caused by obesity and 
the injury to the figure in women are the common complaints. Walk- 
ing and exertion of all kinds are difficult, while the breathing is 
short and the heart's action is embarrassed. The pulse is apt to be 
more rapid, and the urine is scant compared with the amount of 
fluid taken, — because of easy perspiration, and for the same reason, 
colds are more frequent. Indigestion may develop, and constipation 
and piles are common. Impotence sometimes occurs in the male. 
Sleepiness is frequent in fat young people, as made famous by the 
fat boy in "Pickwick Papers." Common observation shows us, 
however, that obesity is compatible with not only long life but with 
great activity and vigor. 

Treatment. — All reduction cures are starvation cures. Xone 
supplies enough food for the permanent needs of the body. It is a 
reduction of quantity rather than quality of food which counts : 
still the kind of food is of importance. The amount of food given in 
reduction cures is equal to from one-half to as low as one-third of 



OBESITY 585 

that required to maintain a normal individual. The fat of the body is 
thus burned up to supply the individual's needs. The danger lies 
in the fact that not only the fat but the substance of the muscles and 
tissues generally may also be broken up if the starving is continued 
too long. If this happens the subject will feel weaker. JSTo reduction 
cure should be continued unless the patient feels stronger for it. 
Frequent meals tend to prevent a feeling of weakness. As a general 
rule dieting is not advisable for persons over fifty or under twenty 
years of age. Those who have been fat for a great many years are 
not favorable subjects for reduction. While reduction is always 
better undertaken with a physician's care it should never be carried 
out by the patient unless otherwise in good general health. The 
reduction of fat in certain disorders, as in diabetes and consumption, 
might be fatal. 

A patient should not lose more than six to eight pounds a month 
for two or three months ; then the diet may be increased so that the 
weight is maintained at a level for two months, and the cure insti- 
tuted again. None but robust individuals should lose as much as 
forty or fifty pounds in a year and they should feel stronger for it. 
Fatness in children should be discouraged by the avoidance of 
sweets, starches — as cereals, and fats — and by the use of outdoor 
exercises, but not by a strict diet. 

Food is generally divided into fats, starches, sugar, and proteids. 
The last include pure meat and fish — free from fat — skim milk, 
white of egg, and a portion of vegetables, as gluten in flour. Pro- 
teids build tissue in the growing and repair it in adults, but do not 
ordinarily make fat. Sugar, starches, and fat make fat and must be 
chiefly cut out in the reduction diets. 

In the following diet list the fat is but one-third to one-half and 
the starches and sugars but one-fifth to one-half of the amount re- 
quired in a normal diet, while the amount of proteids is about the 
standard for normal adults. The special diets given in most medical 
textbooks are of German origin, as Oertel's, von Noorden's, Ebstein's, 
etc., and include articles often not palatable to us, as cold meat for 
breakfast, Rhine wines in considerable amount, etc. 

The following diets are often advised. 



586 DISOEDEBS OF NUTEITION 

The Oertel cure requires that the liquid be reduced to two aud 
one-half pints, including water and all other fluids taken in the 
twenty-four hours, thus: — 

Breakfast : — 6 ounces of tea or coffee with milk ; 3 ounces of bread. 

Lunch : — 3 to 4 ounces of soup ; 7 to 8 ounces of meat ; a little fish ; 
1 ounce of bread or sago, rice, tapioca pudding; 3 to 6 ounces of fruit 
for dessert ; 1 glass of water. 

Afternoox Tea: — 6 ounces of tea and a glass of water; 1 ounce 
of bread. 

Supper: — 1 or 2 soft boiled eggs; 1 ounce of bread; small slice 
of cheese; salad; fruit; 1 to 2 glasses of liquid. 

von iN"oorden's diet follows: — 

Breakfast, 8 a.m.: — Lean meat — 2% ounces; 1 cup of tea, with 
spoonful milk, no sugar; bread — 5/6 of an ounce. 

Tex a.m. : — 1 egg. 

Twelve m. : — 1 cup of strong meat broth. 

One o'clock : — A small plate of vegetable and meat soup ; 5 ounces 
of meat and fish ; 3 ounces of potatoes with salad ; 3 1/3 ounces of fresh 
fruit without sugar. 

Four o'clock : — 6y 2 ounces of fresh fruit. 

Six o'clock : — y 2 pint of milk with tea. 

Eight o'clock: — 4 ounces of cold meat or 6 ounces of raw meat 
cooked and eaten with salad ; 1 ounce of Graham bread ; 2 or 3 spoonfuls 
of cooked fruit without sugar. 

The amount of liquids as water, weak tea, or lemonade at or 
between meals is not limited, von Xoorden believes the numerous 
small meals prevent weakness. 

Bouchard's diet consists wholly of the following : 

214 pints of milk and 5 eggs per day — in other words, a glass of 
milk and 1 egg at 7 and 11 a.m. and 3, 7 and 11 p.m. for 20 days. 

Most of the diets cut down on starches, fat, and sugar required 
in a normal diet while increasing from one-third to one-half the 
amount of proteids as represented by meat, fish, milk and egg. They 
represent about one-half the food value required by the normal 
person. 



OBESITY 587 

The so-called milk cure is one of the simplest diets and may be 
used also in disease of the heart or kidneys (omitting meat in the 
latter) as it increases the action of the kidneys and is particularly 
applicable in the case of persons with much abdominal fat. 

Milk Cure Diet 

Breakfast: — 1 pint of milk. 

Lunch : — 6 ounces of lean meat with green vegetables, as spinach, 
green peas, string beans, lettuce (no bread or potatoes, but beets, tur- 
nips, parsnips, cabbage, Brussels sprouts, or carrots may be used in 
place of green vegetables) ; y 2 P m ^ °f milk; 2 glasses of water or cups 
of tea with a little sugar. 

Five p.m.: — y 2 pint of milk or junket; 2 cups of tea with a little 
sugar. 

Supper, 7 p.m. : — 1 pint of milk and 2 apples (they may be cooked). 

In place of the mid-day meal only a pint of milk may be taken in 
the case of robust persons. If the subject remains at home he may take 
the milk more frequently — 8 to 9 glasses daily — with only the apples, 
tea, and water — if the noon meal is abstained from. 

Ebstein's diet contains three pints of liquid, including two cups 
of tea, as follows: 

Breakfast: — Bread — 2 ounces with plenty of butter (bread may be 
toasted) ; large cup of tea at end of meal, without sugar. 

Lunch: — Fat meat, ham or fish — 4 oz., or 1 egg; bread-and-butter 
— 1 oz. ; green vegetables or salad and fruit. 

Tea: — 1 cup of tea; 1 slice of bread-and-butter, or biscuit. 

Dinner : — Clear soup ; meat — 5 or 6 oz. ; cabbage, peas, string beans, 
or spinach, as much as wanted ; raw fruit or salad ; small piece of cheese 
and a cup of tea at end of meal. 

Five glasses of water should be taken between meals. This diet 
allows fats but excludes starches and sugar, and contains half the normal 
food requirements. 

Dr. E. A. Locke's diet has been found by the writer the most 
sensible and is in accord with our customs. It follows : — 

Breakfast: — 1 cup of black coffee (no cream or sugar); 1 or 2 
boiled or poached eggs; 1 or 2 small slices of toast without butter; an 
orange, apple, pear, or y 2 grapefruit. 



DISORDERS OF XUTEITION 

EtEVEX-THiETY a.m. : — 1 glass of milk, buttermilk or some fruit. 
Luncheon: — 1 cup of clear soup; 3 ounces of meat, eggs or fish; 
2 varieties of green vegetables — 2 to 4 ounces each; raw fruit. 

F:vz ?.:.!.: — Tea. without cream or sugar: 1 small slice of toast 
Dinner: — Eaw oysters; lean meat or fish — 4 :: •: ounces; 2 rreen 
vegetables — . to -4 ounces each: salad of fruit or vegetables with a small 

amount :: Fir-::: dressing: ra~ :: unsweetened cooked fruit: iemi- 
tasse of blacrt aoffee. 

Articles To Be Avoided 

Starches: — White to: a toes — except in sin ill azi:oLt — breii. :raok- 
ers. cereals, macaroni, vermicelli, spaghetti, sago, tapioca, corn starch, 
s~ c et potatoes, shell beans, dried peas or beans, corn and nuts. 

S'vzzrs : — Surar. ~;u :iy. i::-o fruits, syrups, fruit preserves, honey, 
marmalade, and sweet sauces. 

Meats : — Pork, bacon, goose, sausage, croquettes. 

Fish : — Suad, fresh salmon, eels, sardines, mackerel, blue fish, and 



Fao- : — Butter, cream, olive oil. bacon, lard, fat meat, and fish. 

Dessert: — Ices, rich puddings, cake. 

Miscellaneous: — Chocolate, alcoholic drinks — except claret and 
Rhine wine — thick soups, milk, cheese, pickles, condiments. 

This diet contains one-third to a little over one-half the food value 
required by a normal person weighing one hundred and fifty pounds. For 
a heavy person the food is correspondingly deficient so that he will live 
on his fat while on the diet. 

Water is not curtailed in Locke's diet, as in many diets for 
reducing fat. but water should only be taken after rising, between 
meals, and at bedtime. 

Water taken at meals increases the appetite, and some authorities 
believe the sorption of food as well. 

It is advisable that the patient should actually weigh his food at 
first and then he can judge later of the amount he should take by 
bulk. The patient should weigh himself daily and keep a weekly 
chart of his weight. The appetite will be hard to curb at first but 
after a few weeks there should be no trouble on this score and the 
strength and appearance should improve. Prolonged chewing lesseus 
the appetite. 



BERIBERI 589 

The diet may be followed until the weight becomes normal for 
the height of the subject; then the diet may be somewhat increased, 
being careful not to take too much sugar, fat, and starches — as pota- 
toes and bread. 

Exercise in a heavy sweater is imperative during the cure, and 
swimming, riding, golf and walking, occupying three-fourths of an 
hour in the morning and one-half hour in the afternoon, are recom- 
mended. Massage will to some extent reduce local accumulations 
of fat, as on the abdomen, but it must be given daily and very 
vigorously for this purpose. Special exercises are more efficient, as 
exercises in bending over for removal of fat on the abdomen. Some- 
times cathartics are necessary, especially on cutting down the bulk of 
food. Some saline, as Carlsbad salts in one-half teaspoonful doses 
(more or less) in a glass of cold water on rising, is suitable. 

The whole success of the treatment depends upon the faithful- 
ness with which it is carried out. If thoroughly done the habits will 
become so changed that it will not be difficult to adhere to a proper 
diet thereafter. 

BERIBERI 

Beriberi is a peculiar disease resulting from disorder of nutri- 
tion, owing to the absence of certain unknown elements, or vitamines, 
in the food. 

Vitamines are substances existing in food and essential to life. 
Certain disorders, as rickets and scurvy in children, scurvy in adults, 
softening of the bones in pregnant women, pellagra and beriberi, are 
caused by food deficient in these substances. Grains, as wheat, rice, 
barley and oats, when deprived of their germ and outer coating, will 
produce beriberi in many birds and animals. Vitamines are also 
destroyed by heat and by drying and pickling. 

Causes. — In the case of beriberi, experience and experiments 
indicate that a diet of rice, from which the outer coat, containing 
the germ, has been removed, is the more common cause. This is 
called white rice or polished rice and is what we ordinarily use. 
In the preparation of white rice, it is steamed, the outer cover- 
ing bursts, the grain is dried, the hulls are removed, and the rice 
is polished in milling. Red rice, covered by its natural coats, 



590 DISORDERS OF NUTRITION 

will not induce beriberi. The most interesting experiments have 
been tried on large numbers of persons, as in the case of the inmates 
of the insane asylum at Singapore, where formerly half of them 
died of beriberi. It was found that the disease could be produced 
or cured at will by feeding first polished and then unpolished rice. 

In India a group of men was given polished, white, Siam rice, and 
they developed beriberi in sixty days, while another group living 
under the same conditions, but eating only unpolished rice, remained 
free from the disease. But when this second group was fed polished, 
white rice beriberi developed within two months. By exchange of 
clothing and contact of the well with the sick it was shown that the 
disease was not infectious or contagious. 

The same results have been obtained in Japan and the Philip- 
pines. As many as 50,000 cases of beriberi arose from the feeding 
of polished rice to the Japanese during the Russian war, but recent 
knowledge of the cause of the disease has enabled the authorities to 
stamp it out. 

Osier states that "there has been no more remarkable triumph 
of modern hygiene than Takagi's dietetic reforms in the Japanese 
navy." Schaumann and others went further and concluded that 
deficiency in phosphorus, as it occurs in combination in vegetable or 
animal tissue, is the true cause of the disorders of nutrition above 
mentioned. He and others found that rice which contained less 
than 0.4 of one per cent, of phosphorus is likely to produce beriberi. 
This conclusion has not been wholly accepted since Funk claims 
to have isolated a new substance, or true vitamine, the deficiency of 
which in food is the cause of beriberi and which does not contain 
any phosphorus. 

It is unquestionably a fact that the feeding of the polishings or 
bran of rice will cure beriberi and it seems probable that food con- 
tains often more than one vitamine and that various kinds are 
essential to life. Thus in milk there is a vitamine which is de- 
stroyed by heating, and pasteurized milk may cause scurvy. But 
there are other vitamines in milk which survive heat, for in 
dried milk the vitamines are still present that will cure beriberi 
and that are essential for growth of young animals. When there 



BERIBERI 591 

is a deficiency of vitamine in food the animal or man mnst use up 
that already in the body so that some of the tissues are damaged. 
In the case of beriberi it is the nervous system which becomes in- 
volved. 

At present we must confess our ignorance of the precise nature 
of vitamines, although evidence points to either phosphorus or nitro- 
gen as being their most likely chemical constituents ; but we do 
know that many foods contain essential unknown substances which 
are destroyed by removal of the germ and hulls of grains, or by boil- 
ing, heat in any form, drying, canning and pickling, and that defi- 
ciency of these bodies in food gives rise to the diseases already enu- 
merated. We also know that while rice hulls contain the essential 
vitamine curing beriberi, the vitamine curing scurvy resides in fresh 
vegetables and fruits, as in fresh onions, potatoes, cabbage, lemons, 
limes, oranges, apples, etc. 

White bread, deprived of its bran, cerealin, and the germ of the 
grain, is the most important food from which vitamine is removed, 
but all sorts of prepared foods in which the hulls are taken from 
grains or in which heat is used, as condensed and dried milk, dried 
eggs, infant's and invalid foods, vegetable and meat extracts, and 
canned food or dried or pickled meat, are deficient in vitamines and 
instrumental in causing the disease noted above. This explains the 
reason for beriberi developing on ships where the crew live on pickled 
meat, dried potatoes, rice, white flour bread and biscuit. 

Beriberi has occurred most extensively in the Orient, the Chinese 
and Japanese subsisting largely on a rice diet. The disease has 
existed in the Philippines, India, and South America, among fisher- 
men in Europe and on the Newfoundland Banks, on shipboard, and 
in this country in camps, mines, and asylums. It does not develop 
in persons living on a varied and mixed diet and in good surround- 
ings and circumstances. Poverty, overcrowding, low altitude, heat, 
and exposure to wet favor the disease, but a diet deficient in special 
substances or vitamines is the real cause. 

In the Philippines the United States Government authorities, 
who have made elaborate experiments, are convinced that not only is 
polished rice the cause, but that deficiency in phosphorus is the 



592 DISOKDEKS OF XUTKITION 

essential cause, and that any rice which contains less than 0.4 of one 
per cent, of phosphorus may be regarded as polished. 

Duration — Mortality. — Beriberi takes from twenty days to two 
to four months to develop and may last many weeks or months. The 
death rate varies tremendously — from 2 to 50 per cent. 

Symptoms.' — The disease is essentially an inflammation of the 
nerves throughout the body (polyneuritis). It begins like a bad 
head cold with pains, swelling, and loss of sensation in the limbs. 
There may be complete loss of sensation and power in the arms and 
legs although pain, crawling sensations, and other peculiar feelings 
are common in the limbs. The muscles are tender and may waste 
away ? or there may be extreme dropsy and the whole body swell. The 
breathing becomes difficult, the heart is weak and the pulse rapid. 

Prevention. — Prevention consists in change in the diet depending 
upon the cause — in most cases this will be the substitution of unpol- 
ished or red rice for polished, white rice. 

The Government in the Philippines has forbidden the use of 
polished rice among the native troops and in its institutions. Thus 
in the leper colony there were 309 deaths in 1910 from beriberi but 
after changing the diet from polished to unpolished rice not a single 
case of the disease developed in the following year. There is also a 
duty of two and one-half cents a kilo (2.68 pounds) on polished rice 
imported into the Philippines, in order to discourage the natives 
from using it. 

Treatment. — Improvement in the general hygienic conditions is 
essential in the treatment of beriberi. In addition the use of tea 
made from rice hulls or polishings, or when a liberal diet is possible 
this diet may be given without rice. 

It is a very chronic disease and treatment in hospitals is advis- 
able. There is dropsy or fluid in the cavities of the chest and belly, 
so that rest in bed and saline cathartics tend to drain away the fluid, 
while heart stimulants are often required. 

SCURVY 

Scurvy used to be much more common than it is now. In the 
Civil War there were nearly 50,000 cases in the Union Army. 



SCURVY 593 

Sailors and soldiers have been the common victims, but now the 
disease occurs most often among the poorly fed, on shore. 

Causes. — A diet of bread, meat, and coffee will cause scurvy 
(McGrew). The precise cause is unknown although it is commonly 
said to be produced by a diet containing neither fresh meat, vege- 
tables, preserved vegetables, nor vegetable juices. In the absence 
of vegetables, limes, lemons, or oranges will prevent the disease. 
Hansen's party escaped scurvy by eating fresh bear's meat and 
blood. 

It is also thought that poisonous substances in the food may 
occasion scurvy, as tainted meat has experimentally produced in 
monkeys a disease resembling it. 

Scurvy is due to deficiency of some essential substances in the 
food or of one of the vitamines (See Beriberi). Cooking, heating, 
drying, and processing in the course of manufacturing food products 
destroy the substances which prevent scurvy. Food which is kept a 
long time may cause scurvy, so that substances which exist in fresh 
food protect against scurvy : fresh meat and blood prevent scurvy in 
the absence of vegetables and fruit juices. 

Animals fed for weeks on flours of various grains, minus their 
hulls, or on potatoes which have been dried and then boiled, develop 
scurvy. Milk which is only heated to pasteurizing temperatures 
(145° F.) or higher for thirty minutes, will cause scurvy in children 
unless orange juice or juice of fresh meat is fed at the same time. 
These contain the vitamines preventive of scurvy, rickets and mal- 
nutrition. 

Scurvy in infants is usually caused by pasteurized, condensed or 
boiled milk or infant foods of all kinds, although it occasionally de- 
velops from the mother's breast milk — probably depending upon 
lack of vitamines in the mother's food. Cabbage juice loses its anti- 
scorbutic (against scurvy) action when it is heated to 145° F., but 
lime juice boiled one hour still contains its vitamine against 
scurvy. Because lime juice holds its antiscorbutic property so 
tenaciously, it is employed as the great preventive of scurvy on 
English ships, popularly called "lime juicers." 

Many authorities think that phosphorus is the essential vitamine 



594 DISORDERS OF NUTRITION 

in food which prevents scurvy and pellagra, as well as the beriberi. 
However, this is still but an hypothesis. Certain conditions, as 
fatigue, cold, damp quarters, mental depression and home-sickness, 
favor the development of the disease. It attacks all ages, but is most 
severe in the old. 

Symptoms. — Scurvy begins with general weakness and paleness. 
The skin grows dry and has a dirty hue, the gums become swollen, 
tender, spongy, and bleed easily, and later they may ulcerate and the 
teeth may loosen and drop out. The tongue swells and saliva flows 
freely. The appetite is poor and chewing painful, and the breath 
has a bad odor. The ankles swell, and bluish spots appear on the 
legs which may be raised in lumps above the surface; the patient 
suffers from pain in the legs, which sometimes become swollen and 
hard; the blue spots are also seen on the arms and body, and are 
due to bleeding under the skin, and are induced by the slightest 
bruising. Occasionally there is bleeding from the nose and bowels ; 
the joints are often swollen, tender, and painful. Constipation is 
rather the rule, but in bad cases there may be diarrhea, nausea, and 
vomiting, and the victim becomes a walking skeleton. Mental 
depression or delirium may be present. 

Treatment.* — Kecovery is usually rapid and complete, unless the 
disease is far advanced. Soups, fresh milk, beef juice, and juice of 
two or three lemons or oranges may be given daily at first, when 
the digestion is weak, to be followed later by green vegetables, as 
spinach (with vinegar), lettuce, or carrots, onions, cabbage, and 
potatoes. 

The soreness of the mouth may be relieved by a wash containing 
one teaspoonful of carbolic acid to the quart of hot water. This 
should be used to rinse the mouth several times daily, but must not 
be swallowed. Painting the gums with a two per cent, solution of 
silver nitrate in water, by means of a camel's hair brush, twice daily, 
will also prove serviceable. 

As a tonic, a two grain quinin pill and two five grain Blaud's 
pills of iron may be given three times daily. 

Scurvy is frequently mistaken for either rheumatism or paralysis 
in babies. 



PELLAGRA 595 

Infantile Scurvy 

Scurvy occasionally occurs in infants between three weeks and 
eighteen months of age, and is due to feeding patent foods, con- 
densed, malted, pasteurized or sterilized milk. In using sterilized 
or pasteurized milk, if the baby is given orange juice, as advised 
under the heading Food for Infants and the Sick, scurvy will not 
develop. 

It is now certainly known that feeding cooked milk to babies 
causes scurvy, as has long been the conviction among baby specialists, 
and it is advised that at least three tablespoonfuls of orange juice 
should be fed daily with pasteurized or sterilized milk. 

Symptoms. — The lower limbs become painful, and the baby cries 
out when he is moved. The legs are at first drawn up, and become 
swollen all around the part just above the knees, and there may be 
swelling of the knee-joints themselves. Later the whole thigh be- 
comes swollen, and the baby lies without moving the legs, with feet 
rolled outward, and he appears to be paralyzed, although it is only 
pain which prevents movement of the legs. 

Sometimes there is swelling about the wrist and forearm, and the 
breast bone may appear sunken in. Purplish spots appear on the 
legs and other parts of the body, but may be absent until late in the 
disease. The gums, if there are teeth present, become soft, tender, 
spongy, and bleed easily. There may be slight fever, the tempera- 
ture ranging from 101° to 102° F. The babies grow exceedingly 
pale and restless, and lose all strength. 

Treatment. -—The treatment is very simple, and recovery rapidly 
takes place. The feeding of all patent baby foods, and of condensed 
or sterilized milk must be instantly stopped. A diet of unheated milk, 
beef juice, and orange juice, at least one tablespoonful three times 
daily as directed under the heading, Food for Infants and the Sick, 
will bring about a speedy cure. 

PELLAGRA 

This is a peculiar disease. It had its beginning in Spain (1762), 
spreading to Italy and France, and within six or more years has be- 
come quite prevalent in the southeastern part of the United States. 



596 DISORDERS OF NUTRITION 

Causes.- — Pellagra is not contagious nor is it conveyed by flies or 
other means. It was formerly thought to be due to eating Indian 
corn, especially spoiled corn. Recently the United States Public 
Health Service has declared the cause of pellagra to be the eating of 
too much starch, or in other words, the lack of protein and vitamines 
■ — especially during the winter months in the South. 

The disease is more common in the spring and fall, and return 
of the disorder is also frequent at these seasons. It occurs in persons 
more often between the ages of twenty and forty. 

Symptoms. — The digestion, skin, and nervous system are par- 
ticularly affected. The patient grows weak and depressed and has 
headache. The digestion fails and there is soreness in the mouth, 
nausea, vomiting, and painful, watery or bloody diarrhea. The skin 
on the backs of the hands, face, neck, and feet becomes red and puffy 
and looks as if it were badly sunburned: later it peels, and the skin 
is left thickened and reddened. In the more severe cases blisters 
form. The nervous symptoms include headache, dizziness, mental 
depression, irritability, change in disposition and failure in mental 
powers, so that the patient hears imaginary voices or sees imaginary 
objects. 

Severe cases occur with fever, stupor, delirium, and death, 
within a few weeks. Chronic cases recur in the spring and fall 
from year to year, with failing mentality in many instances, so that 
patients become inmates of insane asylums. 

Prevention and Treatment. — It is affirmed that if the inhabitants 
in the pellagra section will eat sufficient lean meat, eggs, milk, and 
fresh or dried peas and beans, the disease will be prevented and in 
most cases patients will be cured by such a regime. 

Healthy persons living in the pellagra section should see that 
their diet contains a liberal amount of lean, fresh meat. milk. eggs. 
and beans and peas, dried in winter, but not canned. By such means 
the disease may be prevented. Corn should be eaten in but small 
amounts, as it is too rich in starch. The Japanese beriberi is an 
analogous disease apparently caused by eating polished rice, a pure 
starch diet containing no vitamines. 

A daily winter diet for patients of six glasses of milk, four eggs. 



GOUT 597 

and one-half pound of lean meat, with dried peas and beans or pea 
or bean soup, is used as a cure. Patients with little digestive difficulty 
may take, in addition to the foregoing, fruits, potatoes, onions, rice, 
oatmeal and wheat and rye bread — but no corn in any form. 

GOUT 

Gout is a disease of assimilation, apparently caused by reten- 
tion of uric acid and allied substances (purins) in the body, and 
characterized by a tendency to deposit salts of uric acid (sodium 
biurate) in the joints and tissues, especially in the first joint of 
the great toes. 

Following repeated acute attacks of severe pain and swelling in 
the great toe joints, extending over years, the disease is apt to 
attack other joints and produce degenerative changes in the blood 
vessels, kidneys, and heart, and a great variety of other irregular 
general symptoms. 

Causation. — There are certain chemical substances called purin 
bodies, of which uric acid is one, which are derived about equally 
from food and chemical changes in the tissues of the body. Uric 
acid, then, is a substance naturally present in the body; but in 
persons having a gouty tendency there is inability to either burn 
up (oxidize) uric acid, or to freely eliminate it from the kidneys. 
Uric acid in the gouty collects in the blood and is deficient in the 
urine — except during acute attacks of gout. 

Purins are naturally oxidized in the bodies by certain sub- 
stances called ferments (as yeast, or pepsin of the gastric juice). 
The ferments destroying uric acid are chiefly found in the liver 
and kidney, and the excess of uric acid in the blood of the gouty 
may be attributed to imperfect action of the liver ferments in 
destroying purins and to retention of them from impaired action 
of the kidney ferments. 

This explanation is indeed chiefly theoretical at present, and 
some think the excess of purins in the blood due to the presence 
of bacterial growth in the bowels (colon bacilli). It is also un- 
known whether gout is due to uric acid alone or to other purins. 

The damage done by uric acid is thought to be due to mechani- 



■BBBHI 



59S DISOEDEES OF XFTEITIOX 

cal irritation, as it is not poisonous when swallowed or injected 
into the blood. The blood and fluids of the body are alkalin so that 
uric acid never exists as such in the body, but always in the form 
of a salt (sodium biurate). If the blood were made acid, death 
would immediately occur. 

Purins are derived chiefly from the contents of the cells of 
animal tissue (nucleoproteids), although to a much less legree from 
some vegetable cells. Thus milk, cheese, bread, butter, and pota- 
toes are free from purins while the maximum amount found in 
peas, beans, and oatmeal v is four grains to the pound; in meat there 
is twice this amount; while in liver, kidneys, brains, and sweet- 
breads the quantity is much greater — seventy grains to the pound 
in sweetbreads. Beef extract contains a considerable amount of 
purin bodies, and the active principle of tea, coflee, and chocolate 
is a purin (cafTein). 

Predisposing Causes. — Heredity is responsible for about sixty 
per cent, of cases, commonly from the father — as gout is six times 
more frequent in the male. Indolence, and excessive eating and 
drinking, particularly produce gout. It was at its height during the 
acme of dissipation in ancient Rome. An old verse has it that 
"Wine was the father, Eating the mother, and Venus the midwife 
of gout." 

In more modern times there has been more gout in England 
than in all the rest of the world together (Lindsay : Trance fol- 
lows next, while in this country gout has been thought rare — but 
Futcher found it only one-third less prevalent in Baltimore than 
in London. 

Strong wines and malt liquors taken with heavy meals appear 
to especially favor gout. Excessive tippling alone does not lead to 
gout, and in Ireland and Scotland the consumption of whisky does 
not cause it, as do ales, porters and port wine in England. Sweet 
champagnes and Burgundies are gouty, but light wines are much 
less b 

Occurrence. — Previous lead poisoning and injuries to joints ap- 
pear to predispose persons to gout. Gout begins in middle life 
(30 to 50) and on an average ten years later in women than in men. 



GOUT 599 

(There were about four cases in the Massachusetts General Hos- 
pital among 28,000 patients in ten years, but it is not a disease 
affecting hospital patients.) 

Acute Attacks. — There may be certain premonitions, as 
twinges of pain in fingers or toes, restlessness at night, asthma, sore 
throat, cough, indigestion, headache, mental irritability, and pas- 
sage of high-colored urine. 

The patient is awakened in the early morning hours with ago- 
nizing pain in the first joint of the great toe, more often the right. 
The pain is burning, or as though the parts were held in a vise. 
The toe swells and is red, hot, and tender, but never develops into 
abscess formation; the pain usually abates as the morning wears 
on, only to recur each morning for several days, and perhaps a 
week. The trouble may then cease and the patient feel most un- 
usually well, but similar attacks may be repeated in the spring and 
fall, or three or four times a year. 

Proper diet and exercise may avert further attacks ; on the other 
hand, any excess in eating or drinking (even a single glass of 
champagne), injury to the joints, mental worry or shock, may 
precipitate a seizure. 

During an acute attack the other toe may become involved and 
in later seizures the other joints, as the ankle, knee, wrists, thumbs, 
and small joints of the hands. In an attack the uric acid is de- 
posited in the joint, first in a form which tends to set up an acute 
inflammation, and if the disease becomes chronic, the salt of uric 
acid (sodium biurate) is found in a pure state in the ligaments and 
cartilages of joints, and sometimes the skin is destroyed over the 
knuckles of the fingers so that lumps of chalky matter come away. 

During the acute seizure there may be general symptoms as 
fever (temperature 100° to 102° F.), vomiting, abdominal cramps, 
flatulence, loss of appetite, and furred tongue. Earely do serious 
symptoms appear, as violent abdominal pain, vomiting and diar- 
rhea, or pain about the heart with difficult breathing, or delirium 
and unconsciousness. These have been attributed to the attack not 
spending itself externally but "striking in," when too rapid disap- 
pearance of the trouble in the toe is experienced. Such grave 



600 DISOEDEES OF NUTRITION 

conditions are now thought to be due to changes in the heart, kid- 
neys, blood vessels, brain, etc., from the effects of the disease. 

Cheoxic Gout. — Chronic gout usually follows repeated at- 
tacks of the acute form, but occasionally in the old, the weak, and 
in women, the trouble is chronic from the beginning. 

There are permanent painful swellings of the joints of the hands 
and feet, and perhaps of the knee, elbow, and spine, but rarely of 
the knee or hip. These may be subject at times to increased pain, 
redness, and swelling with fever. 

This form of gout may be mistaken for the many other forms 
of chronic joint disease called commonly rheumatic, if the patient 
has not had the typical acute attacks of gout described above. The 
true diagnosis can only be made as noted below. 

Goutiness or Complications of. Gout. — In persons who have in- 
herited the gouty tendency, and those who have lived in a manner 
to acquire gout, there may be various irregular symptoms of the 
disease without the occurrence of a typical attack. Thus such per- 
sons are subject to so-called biliousness or indigestion with nausea, 
furred tongue, bad taste in the mouth and constipation, and also 
to eczema, hardening of the arteries, apoplexy, chronic kidney and 
heart disease, with irregular pulsations and palpitation of the heart. 

Nervous symptoms are also frequent in gouty people, as hot and 
itchy or "fidgety" feet at night, or hot and itching eyeballs, cramps 
in the leg, headache, neuralgias, and sciatica. Uric acid is often 
deposited as stone in the kidney, and bronchitis and eye inflamma- 
tions are frequent occurrences. Obesity and diabetes are not rarely 
complications. 

The deposit of the salts of uric acid in various parts of the 
body is commonly observed, especially in the form of small, whitish 
lumps at the edge of the rim surrounding the upper half of the ear. 

Diagnosis. — When a person has had the typical attacks of severe 
pain and swelling in the great toes the diagnosis is easy, but these 
are often absent in gout. With chronic joint disease, not starting 
in the feet, the history of alcoholic excess in a male and the pres- 
ence of the nodules in the ears would suggest gout, but careful 
study by a physician is required to make a satisfactory diagnosis. 



GOUT G01 

In no other joint disease are accumulations of chalky matter 
seen, as in the knuckles and other parts in gout. In women past 
the "turn of life" it is common to find small painless lumps on the 
last finger joints, but these are due to so-called rheumatic gout 
(see separate heading), which has no relation to true gout. In 
countries where gout is prevalent the existence of chronic disease 
in many joints in men is more apt to be gout than any other dis- 
order. 

The irregular forms of gout are the most difficult of diagnosis. 
Only when there is a plain history of typical gout in the family 
may one be justified in referring so many diverse ailments to gout. 
The "uric acid diathesis" and "lithemia" are terms which have 
fallen into disuse and disrepute, since they mean nothing. An ex- 
cess of uric acid in the urine has ordinarily no significance. In 
gout the study of the elimination of uric acid in the urine is of 
value in diagnosis, but it can only be undertaken by the laboratory 
medical man and not by the ordinary practitioner, and the patient 
must be put on a special diet. The use of the x-ray is of great value 
in diagnosis. 

Outlook.- — Patients with gout may live to old age, but in any 
special case the condition of the heart, blood vessels, and kidneys 
will give the best indications as to the lease of life. The outlook 
is better when the disease begins after forty and in acute rather than 
in irregular gout. Through care as to diet, exercise, and mode of 
life, the severity and frequency of attacks may be much diminished. 

Treatment. — As gout is one of the diseases in which "the sins 
of the fathers" are often paid for chiefly by the children, it is 
well to begin preventive treatment by bringing up the offspring of 
gouty ancestors in the country so that they may have plenty of 
exercise in the fresh air and sunshine. After adult life is reached 
there should be moderation in eating, both in regard to the general 
quantity and the amount of meat. Eating an excess of food favors 
gout — especially an excess of meat. 

Food free from purins is the ideal diet, as milk, butter, bread, 
cheese, cream, eggs, fresh vegetables, and fruits (except strawberries) . 
Light and dark meats contain about the same amount of purins as 



602 DISORDERS OF NUTRITION 

does fish. A small amount of fish or meat may be allowed once daily. 
There is no trace of purins in green vegetables and the only vegetables 
which contain much are peas and beans. Tea and coffee contain be- 
tween one and two grains to the cup, as against eight grains of purins 
in a pound of meat. 

An abundance of water is also a prime requisite in gout, and this 
is one of the chief benefits derived from going to "springs" rather 
than any special merit in the particular water. 

The articles rich in purins, as brains, sweetbreads, liver, kid- 
neys, clear soups, fish roe, and caviar, are those particularly to be 
avoided by the gouty. Starch and sugar contain no purins, and 
may be taken in moderation. An excess of tobacco hinders the 
elimination of uric acid, and is bad for persons with gout. Al- 
cohol in any form is detrimental to the gouty, but especially malt 
liquors, heavy wines — as Burgundy, port, Madeira, champagne, and 
sherry. Agreeable outdoor exercise is most desirable, as walking, 
golf, riding, and, when the feet are disabled, rowing or canoeing, 
or gymnasium exercises. 

In an acute attack of gout the foot should be kept raised on a 
pillow and, when the patient is in bed, an arrangement must be 
used (cradle) to keep the clothes from pressing on the foot. Cloths 
wet in water, in which is dissolved as much Epsom salts as pos- 
sible, may be kept about the foot and surrounded by rubber cloth 
or oil silk and loose bandage. In some cases a thick covering of 
absorbent cotton and bandage, and the application of a hot water 
bag outside all, will give most relief. 

A single dose of two grains of calomel, followed in eight hours 
by a Seidlitz powder or bottle of magnesium citrate, is always 
useful at the beginning of an attack. 

The diet should be chiefly milk, barley water, toast, and soft 
eggs for a week following an acute attack. In chronic gout drugs 
are not of much value. Proper living with respect to diet and gen- 
eral hygiene are most important. While gout is more often a 
disease of the well-to-do, it is seen in the very poor who drink malt 
liquors and in the descendants of gouty ancestors who live the most 
exemplary lives. 



CHAPTEE VI 
RHEUMATISM AND ALLIED DISEASES 

Rheumatic fever. Muscular rheumatism. Lumbago. Stiff neck. Rheuma- 
tism of the chest. Chronic deforming joint disease. 

RHEUMATIC FEVER 

(Inflammatory Rheumatism — Acute Rheumatism) 

Causes. — This variety of rheumatism is quite distinct, being in 
all probability due to special germs (streptococci). It occurs in tem- 
perate climates during the fall, winter, and spring — less often in 
summer. Persons more often suffer between the ages of ten and forty 
years. It is rare in infants; their pain and swelling of the limbs 
can be attributed more often to scurvy (see preceding chapter) or 
to surgical disease, with abscess of joint or bone. Exposure to 
cold and damp, in persons insufficiently fed, fatigued, or overworked, 
is the most common exciting cause. 

Symptoms.— Rheumatic fever more often follows tonsillitis or 
other sore throat, and begins with fever and pains in the joints. The 
joints rapidly become very painful, hot, red, swollen, and tender ; the 
large joints, as the knees, wrists, ankles, and elbows, being attacked in 
turn, the inflammation skipping from one joint to another. The mus- 
cles near the joints may also be somewhat swollen and tender. With 
the fever, which may be high (the temperature ranging from 102° 
to 104° F.), there are rapid pulse, copious sweating, and often the 
development of various rashes and minute blisters on the skin ; 
there is also loss of appetite, and the bowels are constipated. The 
urine is usually very dark colored. Altogether, victims of the 
disease are truly pitiable, for they suffer agonizing pain, and are 
unable to move without increasing it. The weakness and prostra- 

603 



604 RHEUMATISM AND ALLIED DISEASES 

tion are marked. Anemia develops more markedly than in any 
other fever. Small, hard lumps, ranging from the size of a shot 
to that of a pea, sometimes appear on the skin of the fingers, hands, 
wrists, knees, and elbows. These are not tender ; they last for weeks 
and months. They are seen more often in children, and are most 
characteristic of rheumatic fever, but do not appear until late in 
the disease. 

Complications of rheumatic fever are many. In about one- 
half of the cases the heart becomes involved, and more or less per- 
manent crippling of the heart persists later in life. Unconscious- 
ness and convulsions may develop more often when the fever runs 
high. 

Lung trouble and pleurisy are not infrequent. Chorea or St. 
Vitus's dance follows inflammatory rheumatism, in children, in 
some instances. Repeated attacks at intervals, varying from one to 
four and five years, are rather the rule — more particularly in young 
persons. 

Acute rheumatism frequently takes a milder form, with slight 
fever (the temperature not over 100° to 101° F.) and slight pain 
and swelling of the joints. In children this is a common occur- 
rence; the child keeps about, fever and other symptoms being so 
slight as to escape notice, except for vague, so-called "growing pains." 
But heart disease is apt to follow, and, therefore, any joint pain 
in a child should receive a physician's attention at the earliest 
moment. Recovery from rheumatic fever is the usual result, but 
with an increasing tendency to future attacks, and with the 
possibility of more or less permanent weakness of the heart — for 
acute rheumatism is the most common origin of chronic heart 
troubles. 

The milder form often follows the more severe, and may per- 
sist for a long time. The duration of rheumatic fever is variable; 
in severe cases the patient is bedridden for about six weeks. 

There are numerous other fevers in which inflammation of the 
joints may occur. Among these are included gonorrhea, pneumonia, 
scarlet fever, blood poisoning, diphtheria, etc. The joint trouble in 
these cases is caused by the special germ which occasions the original 



EHEUMATIC FEVER 605 

disease, and the joint inflammation is not in any way connected with 
rheumatism. 

Gout and acute deforming arthritis may mislead. The constant 
attention of a physician is emphatically demanded in every case of 
rheumatic fever, since the complications are so numerous, and since 
permanent damage of the heart may be prevented by proper care. 
Only frequent examinations of the heart will reveal the presence 
or absence of heart complications. 

Treatment.' — It appears extremely doubtful whether rheumatic 
fever can be cut short by any form of treatment. The disease 
is self-limited, that is, it will pass away of itself after a certain time. 

The pain, however, can be rapidly abated by treatment. Warmth 
is of great value. It is best for the patient to sleep between blankets 
instead of sheets, and to wear flannel nightgowns, changing them 
as often as they become damp with sweat. To facilitate the chang- 
ing, it is well to have the nightgowns slit all the way down the 
front, and also on the outside of the sleeves. Wrapping the joints 
in cotton batting and applying splints to secure absolute rest are 
great aids to comfort. The diet should be fluid, consisting of 
gruels, milk, broths, and soups. To relieve pain in the joints, cloths, 
wrung out of a saturated solution of Epsom salts or baking soda 
and very hot water, wrapped about the joint and covered with oiled 
silk, will be found extremely serviceable. Oil of wintergreen is 
another remedy which has proven of value when applied to the 
joints on cloths saturated with the oil and covered with cotton wool. 

The bed must be smooth and soft, with good springs. High 
fever is reduced by the employment of cold to the head and by spong- 
ing the body with cool water at intervals of about two hours. 

The two drugs of most value are some form of salicylic acid 
and an alkali. Sodium salicylate in solution in water should be 
given to the adult in doses of ten to fifteen grains every two hours 
until the pain is relieved, and then once in four hours, as long 
as the fever lasts. At the same time baking soda, one-half a level 
teaspoonful dissolved in water, should be administered every three 
hours, and this may be continued as long as the fever persists. 

The patient must use a bedpan in relieving the bladder and 



606 EHEUMATISM AND ALLIED DISEASES 

bowels, and should remain in bed for a great while if the heart is 
damaged. It is a disease which no layman should think of treating 
if it is possible to obtain the service of a medical man. 

Prevention. — The surgical removal of enlarged or diseased ton- 
sils, or teeth abscessed at their roots, is always advisable to pre- 
vent both rheumatic fever and chronic forms of so-called rheuma- 
tism. Experimentally it has been found possible to reproduce the 
heart and joint conditions present in rheumatic fever by injections 
of germs (streptococci) from diseased tonsils or teeth (See p. 609). 
Conversely, removal of diseased tonsils undoubtedly cures acute and 
chronic forms of what is commonly called rheumatism. 

In the course of rheumatic fever it may even be advisable to cut 
out diseased tonsils. 

The germs (streptococci) causing tonsillitis enter the blood of the 
patient and have a special predilection for the valves of the heart 
(producing valvular disease of the heart), the joints (causing rheu- 
matism), and the nervous system (inducing St. Vitus' dance). 
These conditions are therefore practically one and the same disease — 
beginning with entrance and growth of streptococci in the tonsils. 

MUSCULAR RHEUMATISM 

(Myalgia) 

In this disease there is pain in the muscles, which may be con- 
stant but is more pronounced on movement. 

Exposure to cold and wet, combined with muscular strain, fre- 
quently excite an attack. On the other hand, it often occurs during 
hot, dry, fine weather. Attacks last usually but a few days, but 
may be prolonged for weeks. 

The pain may be dull, as if the muscle had been bruised, but 
is often very sharp and cramplike. There is commonly slight, if 
any, fever and no general disturbance of the health. The following 
are the most common varieties: 

Lumbago. — Lumbago attacks the muscles in the "small of the 
back." It comes on often with great suddenness, as on stooping 
or lifting. It may be so severe that the body cannot be moved, and 



MUSCULAR RHEUMATISM C07 

the patient may fall in the street or may be unable to rise or turn 
in bed. In less severe cases the pain "catches" the patient when 
attempting to straighten up after stooping. 

Pain in the back is often attributed by the laity to Bright's 
disease, but is not seen in the latter disorder, and is much more 
often due to sprain, flat feet or rheumatism. Pain caused by sprain 
of the back (sacro-iliac joint), which is so common, is frequently 
mistaken for rheumatism in the back, or lumbago, but there is 
usually a history of some fall, jar, or blow in the production of 
sprain, and it is located more precisely over the joint. 

Stiff ISTeck. — This is a very common variety of muscular rheu- 
matism, and is seen more especially in young persons ; it may appear 
very suddenly, as on awakening. 

It attacks the muscles of one side and back of the neck. The 
head is held stiffly to one side, and to turn the head the body must 
be turned also, as moving the neck causes severe pain. Sometimes 
the pain on moving the neck suddenly, or getting it into certain posi- 
tions, is agonizing, but when it is held in other positions, a fair 
amount of comfort may be secured. There is a form of inflam- 
mation of the muscles of the back of the neck and head, in which 
small, hard, painful lumps are felt, and this condition is often asso- 
ciated with severe headaches and is relieved by massage. 

Rheumatism of the Chest. — In this form there is more or 
less constant pain, much increased by coughing, sneezing, and tak- 
ing long breaths, or by movements. It usually attacks one side, more 
often the left. It may resemble neuralgia or pleurisy. 

In neuralgia, the pain is more limited and comes as sharp, 
rapid, darting stabs of pain with intervals of freedom from suf- 
fering, and there are painful spots. The absence of fever in rheu- 
matism of the chest will tend to distinguish it from pleurisy, in 
which there is more often cough. Examination of the chest by a 
physician, to determine the condition of the lungs, is the only method 
of making an exact diagnosis. 

Muscular rheumatism also affects the muscles about the shoul- 
der, shoulder blade, and upper part of the back; sometimes also 
the muscles of the belly and limbs. 



608 RHEUMATISM AXD ALLIED DISEASES 

Treatment. — Rest, heat, and rubbing are the most satisfactory 
remedies. In stiff neck chloroform liniment or analgesic ointment 
should be well rubbed into the affected parts several times daily. 
The patient should lie with the painful part on a hot water bag, 
or a thick, hot, flaxseed poultice may be applied to the neck and 
kept warm with a hot water bag. Lumbago is often immediately 
relieved by encircling the whole lower part of the trunk with strips 
of surgeon's adhesive plaster, as recommended in the forepart of 
this chapter for sprain of the back. Rest in bed with a hot water 
bag under the "small of the back" is also of service; or a piece 
of flannel may be laid on the back, over the plaster, and the flannel 
may be ironed with an ordinary hot flatiron. Two or three com- 
pound cathartic pills should also be taken, as a free movement of 
the bowels may cure the trouble. 

In rheumatism of the chest strapping of the chest, as for broken 
rib, will be most successful — together with the application of a hot 
water bag while the patient is in bed. A patient with stiff neck, 
lumbago, or rheumatism of the chest, may be much benefited by 
taking a capsule hourly, containing ten grains of aspirin, followed 
each time by a whole glass of water. After taking five or six doses, 
or if ringing in the ears is produced, the drug should be discon- 
tinued for a time. 

In addition to securing a free action of the bowels, in all cases 
of muscular rheumatism, it is well to encourage elimination from 
the kidneys by the drinking of one quart of lemonade daily in which 
two teaspoonfuls of cream of tartar is dissolved. 

CHRONIC DEFORMING JOINT DISEASE 

Our conception of chronic joint disease has been greatly changed 
by modern research. Formerly the terms rheumatic gout, rheu- 
matoid arthritis, and chronic rheumatism, were used with the idea 
that they described distinct diseases. JSTow we realize that the term 
chronic rheumatism should be abolished because it has no meaning 
and is likely to lead the user of the term to employ the old valueless 
remedies for rheumatism. Acute rheumatic fever is the only form 
of rheumatism now recognized. 



CHRONIC DEFORMING JOINT DISEASE 609 

Causes. — Chronic joint disease is in almost all cases due to 
local inflammations in various parts of the body, and is caused by 
a variety of germs. These germs find their way into the blood, 
and in this fluid they invade the joints where they produce the 
changes seen in chronic inflammations of the joints. In chronic 
joint disease then, the patient needs the most careful study in order 
that the doctor may discover any local inflammation in any part 
of the body which may be the cause of the joint disorder. 

While the cure of such existing local infections commonly re- 
sults in improvement or recovery of the joint disease, in some in- 
stances such is not the case. It may be that chemical products 
sometimes explain the origin of chronic joint disease, and many 
cases are thought to be caused by the absorption of poisonous sub- 
stances from the bowels in the condition known as enteroptosis, 
owing to retention of the intestinal contents. 

The following conditions are now recognized as the most fre- 
quent causes of chronic joint disease : 

(1) Chronically enlarged and diseased tonsils. These are most apt 
to occur in persons who have had acute tonsillitis. Kemoval of 
diseased tonsils should always be done in chronic joint disorder. 

(2) Inflammation of the gums, with formation of "matter" or pus, 
followed by shrinking of the gums and loosening of the teeth (called 
Riggs' disease) and also abscesses so common at the roots of dead 
teeth, as shown by x-ray, may lead to chronic joint disease. 

(3) Inflammation of the cavities connected with the nose (sinus 
disease) is another fruitful cause of chronic joint disease in which 
the specialist will be necessary for diagnosis and cure. 

(4) It is thought that chronic inflammation of the gall-bladder and 
appendix may be a source of chronic joint disease, and these may 
be cured by surgery. 

(5) Diseases of the urinary and sexual organs are frequent causes 
of chronic joint trouble: thus, abscess of the kidney, and inflamma- 
tion of the bladder and urinary passages in both sexes, are included 
under this head. Chronic inflammation of the fallopian tubes in 
women and of the prostate and seminal vesicles in men, often due to 
gonorrhea, have been found causative factors. The local or sur- 



610 BHEOIATISM AND ALLIED DISEASES 

gical treatment of these conditions will often cure or arrest the joint 
trouble. If the joint disease has progressed so that there are present 
deformities due to destruction or outgrowths of bone, the most favor- 
able outcome that can be expected will be relief of pain and arrest 
of the diseased process. 

Symptoms. — Occasionally the disease begins suddenly with fever 
and pain, swelling, heat, and tenderness in several joints. This 
appears at the beginning, like rheumatic fever, but the joints do 
not wholly recover and stiffness and swelling remain. If the joint 
forming the union of the lower jaw and skull is involved it is a 
fairly positive indication of this disease; the joints of the fingers 
and knuckles are also often swollen, tender, hot, and painful in 
this disease. More often the onset is gradual and without fever. 
The joints nearest the tips of the fingers, more often in women, show 
little hard knobs on the sides, and these joints are hot, painful and 
swollen at times. At first only one joint, as of the middle finger, 
may be attacked, and frequently the corresponding finger on the 
other hand is next affected. The joints of the fingers become en- 
larged, deformed, and stiffened. 

The results of the disease are permanent, so far as deformity 
and the stiffness which causes interference with the movements of 
the fingers are concerned, but the disease may be arrested at any 
period of its development, leaving a serviceable, though deformed, 
hand. In these cases the larger joints are not usually involved. 

In other cases the larger joints are involved. A joint will be 
painful, hot, and swollen. Creaking and grating are frequently 
heard during motion of the joint. The condition of the joint 
varies greatly, and improvement is marked at times. Other joints 
are attacked; gradually the joints become misshapen and deformed. 
The larger limbs are often bent and cannot be straightened, and 
the muscles waste away, making the joints look larger. The pain 
may be great and persistent, or slight. Xumbness and tingling of 
the skin may trouble the patient, owing to inflammation of the 
nerves (neuritis), and the skin is sometinles smooth, glossy or freck- 
led. In the worst cases the patients become absolutely crippled, 
helpless, and bedridden, and the joints immovable. Even though 



CHRONIC DEFORMING JOINT DISEASE 611 

most of the joints become useless, there is frequently sufficient sup- 
pleness in the fingers to allow of their use, as in writing and knitting. 

In old men the disease is seen attacking one joint, as the hip 
or shoulder. The disease also affects the spine, more often the mid- 
dle or below, so that there is great stiffness and pain in the back 
and down the legs. This is seen more commonly in men and is 
brought on in part by injury. The disease attacks children — more 
often girls — before the sixth year. Beginning often with fever and 
slight stiffness in one or two joints, the disease progressively at- 
tacks other joints. These later cannot be moved, and there is much 
swelling of the soft parts about them, as also wasting of the muscles. 
The glands are generally enlarged and there is sweating and pallor. 

Outlook. — The majority of patients with deforming joint disease 
recover and have good health apart from the stiffness of their joints 
and the permanent deformity; those cases which start at the change 
of life in women are not so hopeful. The cases which begin with 
fever are the most favorable; some of the cases in children make 
a good recovery. Persons with disease of the spine rarely become 
wholly crippled and suffer from stiffness, and at times pain. 

The pulse is often rapid in this disease, but true heart compli- 
cations are rare. Dyspepsia is a frequent accompaniment. 

Treatment. — Deforming joint disease is a chronic disorder in 
most cases, and requires the careful study and continuous care 
of the medical man. He may frequently arrest it in the earlier 
stages and prevent a life of pain and helplessness. The great hope 
is in the finding of a special inflammation in some part of the body, 
the relief of which may cure the joint trouble as well. 

Nourishing food, as meat, cream, eggs and butter, is desirable. 
Various forms of baths are useful, especially the hot air bath or 
baking. The wearing of flannel is advisable and a warm climate is 
favorable so that the patient may be outdoors as much as possible. 
Mechanical measures are of great service, as the fixing of joints 
in splints, the plaster jacket in spinal trouble, and, later, the use 
of massage and movements of the joints. Medicines have little spe- 
cial value in directly curing the disease. Surgical treatment will 
sometimes overcome the crippling and deformities. 



612 RHEUMATISM AND ALLIED DISEASES 

It is probable that all chronic joint disease (except gout) is due 
to infection, or some variety of germs, or bacteria. When the va- 
riety of infection or germ is known, as in the joint disease of gonor- 
rhea and tuberculosis, these names are used as a prefix and the joint 
troubles are spoken of as gonorrheal or tuberculous joints. 



CHAPTEK VII 
NEKVOUS DISEASES 

Neurasthenia. Hysteria. Insomnia. Headache. 

NERVOUS EXHAUSTION— NERVOUS DEBILITY 

(Neurasthenia) 

Nervous exhaustion is by far the most frequent of the nervous 
diseases, especially in the United States, on which account it has 
been called the American Disease. 

The condition was first described and named by Beard, of New 
York, in 1879. He denned it as a state in which there is a de- 
ficiency of nerve force, shown by undue sensitiveness (and reaction) 
to external impressions. Mental impressions are greatly exag- 
gerated. What would be but a molehill to the robust, becomes mag- 
nified so that it appears as a mountain; a nervous strain, borne 
without trouble by the strong, results in nervous collapse; slight 
muscular effort occasions fatigue out of all proportion to the cause. 

Causes. — No case is found, as a rule, to be due to any one cause. 
Usually several causes are responsible. Heredity plays an important 
part. Weakness and instability of the nervous apparatus — a neu- 
rotic temperament — is frequently inherited from parents, them- 
selves the victims of nervous or mental troubles, or addicted to 
excesses of some kind. It may be due to faulty development and 
nutrition of the child while yet unborn. 

Persons with neurotic temperament may be healthy if no con- 
tinuous strain be sustained by them, but they have no reserve capi- 
tal of nerve force, and easily succumb. Persons not born with weak 
nervous systems may acquire nervous exhaustion through mental 
and phj^sical overwork, prolonged emotional excitement, care, 

613 



614 NERVOUS DISEASES 

anxiety, or grief. Worry is both a cause and an effect of nervous 
prostration. 

Certain occupations are more favorable to the development of 
the disease. Thus, teachers, brokers, bankers, journalists, business 
men, and women fretted by manifold household cares, are especially 
prone to nervous prostration. Poisons produce the condition, so 
that alcoholics and tobacco in some, morphin and the poisons of 
grippe, typhoid fever, and syphilis in others, are not infrequent 
causes. Sexual excesses, prolonged sexual excitement, and abuse of 
the sexual organs in the young occasion nervous debility, although 
the dread of the consequences is often a more potent factor than 
the damage done in the case of the latter misfortune. The strong 
emotional excitement induced by the longings, doubts, fears, and 
hopes of love and religion is also responsible for its share of neuras- 
thenia. Diseases of special organs may so exhaust the nervous 
system as to cause general prostration. 

A faulty sexual hygiene before or during married life is prob- 
ably the most common cause of neurasthenia. Vlien such can be 
cured, the nervous prostration is likewise relieved. Injuries to the 
head and back not at all uncommonly give rise to nervous exhaustion, 
even in the strongest persons. Trepidation -over suits, or claims 
for damages, increases neurasthenia. 

Symptoms.— Xervous exhaustion occurs more frequently between 
the ages of twenty and forty; both sexes are subject to it. Patients 
are usually of a spare figure, but occasionally are very stout. 

The symptoms are more numerous and varied than in any other 
disorder known, while the actual alteration in the anatomy or struc- 
ture of the nervous system, if any, is unknown. 

Among the most frequent symptoms are : a feeling of pressure 
and fatigue in the top and back of the head ; pain in the lower part 
of the spine and back of the neck ; muscular weakness, as in walking : 
numbness, and creepy or crawling sensations in the skin : or feelings 
of heat or cold, imaginary feverishness, or general chilliness; and, 
again, burning, hot flashes, sweating, and flushing of the surface. 
A dragging, tired feeling in the eyes, or flashes of light, are among 
the most common complaints. Tender spots along the spine, usually 



NERVOUS EXHAUSTION— NERVOUS DEBILITY 615 

in more than one locality, and morbid introspection, or self-analysis 
of symptoms, are very common. 

There is often despondency, confusion of the mind, and inability 
to fix attention, so that it becomes almost impossible for the patient 
to add a column of figures or dictate a letter. The emotions are 
under poor control, and patients may weep on the slightest cause. 
Thoughts which cannot be controlled may constantly run in the pa- 
tient's mind. The temper is apt to be irritable or moody, and the 
subject forever is fearful and anxious about himself. He imagines 
he is becoming insane, is afraid to ride on the cars, to go among 
crowds, to be alone, fears tall buildings will fall on him, dreads 
fatal disease, thunder and lightning, etc. The sleep is variable; 
there is commonly sleeplessness, occasionally the opposite condition. 
The digestion usually suffers; the symptoms of special digestive 
diseases may be present {See Nervous Dyspepsia). Constipation is 
frequent. 

Pain and distress in the region of the heart, and violent, rapid, 
and irregular heart action are frequent causes for complaint. Dis- 
orders of the sexual organs are the rule : in women, disordered men- 
struation and pain in the ovaries; in men, inability to perform the 
sexual act, or great exhaustion after it, or premature discharge 
from the sexual organ. Muscular weakness is shown at times, in 
severe cases, by unsteady, uncertain, and trembling gait; sometimes 
by difficulty in enunciating and in writing. 

Pain may be felt anywhere — in the skin, head, neck, muscles, 
joints, or some internal organ. While all the symptoms enumerated 
never attack the same patient at any one time, they are apt to be 
more or less troublesome at different times, some being prominent in 
some persons, others in other individuals. Occasionally only one 
symptom is at all salient, and in that case the determination of 
the causes is difficult. 

Outlook.- — The outlook as to life is favorable: patients very 
rarely either die or have their lives shortened by nervous prostra- 
tion. The disease has a tendency to be chronic and, even under most 
favorable circumstances, there may be relapses; in these cases the 
patient's courage and hope are sadly taxed. 



616 NERVOUS DISEASES 

The degree of cure depends upon the nature of the exciting 
causes, and whether these can be removed, e. g., upon the amount 
of inherited weakness; upon whether stress and strain may be re- 
moved; upon the duration of the disease before treatment is at- 
tempted; and also upon the ability and will to follow out treat- 
ment. The nervous capital will always be small, and, therefore, 
extra calls made upon it are liable to lead to bankruptcy. 

Nervous debility which is not inherited, but acquired through 
some disease of special organs, may be entirely cured if the cause is 
removed. Cases due to accidental injury are often of grave import. 

Diagnosis. — This is best made by a physician, after a thorough 
examination of the patient. In no disease is this more essential, 
since the symptoms are so varied and resemble those peculiar to so 
many other diseases. 

One characteristic feature of nervous exhaustion is the very 
variety of symptoms, and their liability to change and shift. An- 
other feature of importance is the tendency to improvement, when 
the surroundings and circumstances are favorable to happiness and 
well-being. 

Treatment.' — The first endeavor in any rational treatment is to 
remove the causes — whether they be unfavorable environment, cir- 
cumstances, habits, injury, or disease. 

Hereditary influences cannot be abolished, and treatment, as 
Osier remarks, should often have been begun a generation back; 
but neurotic tendencies in children can be overcome in large meas- 
ure by proper training. Children should be brought up, as far as 
possible, out of doors, should receive simple, nourishing food, keep 
regular hours, and have plenty of sleep. Instruction calculated to 
prevent any sexual stimulation should be given, and if any signs 
of nervous disturbance develop at puberty, the child must be taken 
from school and be made to lead an outdoor life in the country. All 
emotional excitement should be avoided, as well as excess in alcohol, 
tobacco, tea, and coffee; if the latter can be absolutely cut off, it 
should be done. The nervous strain incident to long marriage en- 
gagements, to certain occupations, and to the various causes noted 
above, should be shunned whenever possible. 



NERVOUS EXHAUSTION— NERVOUS DEBILITY 617 

In no disease are the support and encouragement of a physician 
more helpful in allaying the morbid fear of the patient that he is 
suffering from a fatal or incurable disorder, in reenforcing the weak- 
ened will, and in restoring hope when relapses occur, than in neuras- 
thenia. 

The newer methods of psychotherapy are quite successful in 
some cases. The requisites for success are: (1) a physician of 
strong personality and ability; (2) the formation of a sanatorium 
or center in some attractive and healthful resort in which the gen- 
eral atmosphere will be conducive to recovery; and (3) the hopeful 
"suggestions" of the doctor and the faith in recovery which he im- 
parts, together with the proper regulation of the patient's life, habits, 
and occupations. 

In patients well enough to be about, one of the chief factors 
in promoting recovery is change of surroundings, habits, work, and 
amusements. In cases resulting simply from overwork, the rest at- 
tained by six months of travel and outdoor recreation will suffice — 
and this is the hackneyed advice. But when this is not possible, the 
hours of work may be shortened and an hour given to rest daily, 
while some form of exercise, as bicycling, riding, rowing, golf, fish- 
ing, hunting, tennis, swimming, or gymnastics, may at the same time 
be undertaken; the patient should choose that which appeals most 
strongly to his taste. 

Total change in the habits — even to the extent of forming some- 
what irregular habits, and to the pursuit of literary work in place 
of outdoor sports — has proved curative, but such an unusual course 
can be advised with safety only by a physician. 

What would usually be called overeating is generally advisable, 
more especially in the thin and pale. A glass of milk, an egg nog, a 
cup of cocoa, a raw egg, or a cup of strained oatmeal should, one 
or the other, be taken between the regular meals and at bedtime. 
Sleeplessness should never be treated with drugs, unless by a physi- 
cian's orders, as hypnotic drugs are usually unnecessary and injurious 
in these cases. A warm bath with a cold compress to the head, and 
a glass of warm milk or of beer, before retiring, are often sufficient. 

Drugs, as a whole, play little part in the cure of nervous ex- 



618 NEKYOrS DISEASES 

haustion, except to relieve certain symptoms. Cod-liver oil is fre- 
quently of value, while iron, in pallor and anemia, also supplies 
an essential constituent of the blood and is recommended. Indi- 
gestion improves more certainly under the general measures sug- 
gested, than by dieting, drug, or local treatment {See Xervous 
Dyspepsia. ) 

Various forms of water cure are of worth. One of the most 
simple is the hot followed by the cold spray, which may be taken in 
the morning from a hose and sprinkler made for attachment to the 
ordinary bathroom faucet. 

For the chronic cases, those too sick to follow the ordinary life, 
and for many weak, thin, and poorly nourished women, who can 
thus only escape from their manifold household worries, the "rest 
cure" originated by Weir Mitchell, of Philadelphia, is the most suc- 
cessful treatment. This implies the complete isolation of the patient 
in bed, usually in a well-ordered sanatorium, for six or eight weeks. 
The treatment comprises large amounts of nourishing food given at 
frequent intervals, with different forcns of water cure, with massage 
and electricity; the patient gives up all responsibility to the doctor 
and nurse, and is shielded from emotion or cares and worries by 
separation from friends and family. 

Gain in flesh in nervous exhaustion commonly goes hand in 
hand with general improvement. A gain of twenty to sixty, and 
even eighty, pounds sometimes results from the rest cure. Exercise 
in nervous exhaustion may be readily carried to excess. Exercise 
should never be followed by more than a healthy fatigue, and should 
be combined with a daily hour of rest on the bed or couch. Walking, 
or merely rest, in the open air is sometimes preferable to exercise 
for women. 

The special disorders which we have noted as often leading to 
nervous exhaustion can, of course, be discovered and treated properly 
only by a physician, and the sooner patients suffering from symp- 
toms suggestive of this disease submit to thorough examination, the 
better. ~No two cases are identical in symptoms, causation, or treat- 
ment required, but information concerning duration before treat- 
ment is very important in every case. 



HYSTERIA 619 

HYSTERIA 

Hysteria is a functional disease of the nervous system charac- 
terized by lack of self-control and increased impressionability, and 
manifested by the most varied symptoms: in fact there is scarcely 
any disease in medicine which hysteria may not simulate. 

Causes.' — Hysteria is seen chiefly in females, beginning more 
often after the age of twelve and occurring frequently in the child- 
less or single, and during menstruation or the "change of life." 
Repression of the sexual nature is thought by some to favor the 
disorder. 

The chief causes are an inherited tendency to nervous disorders 
and improper training. Thus girls who are petted and spoiled are 
less able to withstand the buffets of the world, and desire for sym- 
pathy may tempt them to exaggerate their physical troubles or 
simulate disease. 

The immediate cause of a hysterical attack is usually some emo- 
tional excitement, as an unhappy love affair, grief, worry, family 
troubles, or physical injury. 

Forms. — There are two forms of hysteria: (1) the convulsive 
form, and (2) forms without convulsions. 

(1) The Hysterical Attack or Nerve Storm. — This form usually 
arises from some emotional excitement. It generally begins with 
senseless laughing and crying, sighing, and a feeling as of a lump 
in the throat. This is followed by a choking sensation, palpitation 
of the heart, and difficulty in breathing, and then by a fit or con- 
vulsion. 

The patient may fall and become apparently unconscious; she 
is not unconscious, however (as in epilepsy). The body becomes 
convulsed and the head and arms are thrown about in a violent 
and irregular manner. The hands are clenched with the thumbs 
turned in. Sometimes the body is perfectly rigid, the patient lying 
with the belly arched upward, the head thrown back, and the subject 
resting on the back of the head and heels. The eyes may be open 
and trembling of the eyelids is commonly seen. 

The attack may continue for an interval of from ten minutes to 



620 NERVOUS DISEASES 

several hours, and will terminate in laughing, crying, sighing, and 
sometimes in a stupor. 

This condition is apt to be mistaken for epilepsy in women. 
The points of difference are as follows: In hysteria there is some 
previous emotion, as a cause ; in epilepsy no cause is apparent. 
The symptoms, as choking, lump in the throat, palpitation, laughing 
and crying, seen in the beginning of a hysterical attack, are lacking 
in epilepsy. In epilepsy the subject often bites her tongue; in hys- 
teria the patient may bite her lips, hands, other persons or objects, 
but not her own tongue. In hysteria the patient may talk and 
scream during the attack, but never (except before the attack) in 
epilepsy. The attack in epilepsy rarely lasts more than three min- 
utes: in hysteria not less than ten, and urination and movement of 
the bowels often happen in an epileptic seizure, but never in hysteria. 

The graver forms of hysteria are rarely seen in this country or 
England, when, following an epileptic-like convulsion, the patient 
exhibits emotional excitement and catalepsy, in which the limbs are 
held in grotesque positions for an indefinite period. This may be 
succeeded by positions suggestive of the various passions, and by 
ecstasy, in which the subject has visions, hears voices, and converses 
with imaginary persons. Sometimes the patient ends by falling 
into a trance in which life appears to be almost extinguished — so 
feeble are the pulse and breathing. 

(2) The Hysterical State without Convulsions. — The symptoms 
are so diverse and countless that a mere mention of some of the 
more common must suffice : 

(a) Spasms : These include hiccough, difficult breathing or asthma, 
retention of urine, difficult swallowing, and false or phantom tumor 
of the abdomen — all caused by spasm of the muscles of these parts. 
Contractions of the muscles of the limbs causing deformities, and 
of the muscles of the jaw producing apparent lockjaw, are not rare. 
Ehythmical movements of the jaw, body, or limbs, and fine trembling 
of the hands, head, or leg may be seen. Complete paralysis of 
the less, or of one side of the body, may occur. 

(b) Disturbance of Sensations. — These are frequent in hysteria. 
Loss of sensation to touch, in one-half of the body or in spots, 



HYSTERIA 621 

agonizing pain in the top of the head (as if a nail were being 
driven in), painful spine with very tender spots along its course, 
and pain in the stomach and abdomen simulating that of organic 
disease, are observed. In relation to breathing, hysteria leads to 
gasping breathing, coughing, yawning, sighing, and rarely to cries 
like those produced by domestic animals. There are various recog- 
nized hysterical disturbances of the digestive organs, such as the lump 
in the throat, difficulty in swallowing, persistent loss of appetite, vom- 
iting, distention of the belly, and extreme constipation or diarrhea. 
Violent beating of the heart, rapid pulse, flushing of the skin in 
various parts of the body, and pain about the heart, are often in- 
duced by hysteria. Chronic swelling, stiffness, and pain in the 
knee or hip may occur in hysteria and may be distinguished from 
organic disease with great difficulty. Fever is sometimes of hys- 
terical origin. 

Occasionally hysterical patients inflict wounds upon themselves 
and not infrequently seek surgical operations on slight pretext. The 
mind is always affected in hysteria, the memory is temporarily much 
impaired, and the will power is lessened or lost, so that the patient 
is a ready victim of suggestions, impressions, impulses, ideas, and 
misconceptions originating in the patient or in others. The desire 
for sympathy is paramount. 

Diagnosis. — Certain symptoms are suggestive of hysteria apart 
from the manifestations which suggest other diseases — thus, the emo- 
tional temperament, attacks of weeping and laughing, the complaint 
of lump in the throat, gasping and sighing. There is usually a 
history of previous attacks. 

Treatment. — Hysteria is a disease and not a perverse state of 
mind, as appears to be a not uncommon diagnosis. Harsh treat- 
ment is wholly improper. Proper training in self-control, the rem- 
edying of all physical ailments, and healthy occupation outdoors, 
are useful in preventing the disease. 

The attacks themselves need little treatment, although a tea- 
spoonful of tincture of valerian, or one-half teaspoonful of aromatic 
spirits of ammonia, in half a glass of water, are of service ; also dash- 
ing cold water in the patient's face. Treatment by suggestion, in 



622 NERVOUS DISEASES 

which the patient is persuaded that the symptoms are of no im- 
portance and will disappear, is of great value when given by one in 
authority in whom the patient has implicit faith. 

The rest treatment — in which the patient is treated away from 
home in a sanatorium, and is reeducated in all her habits and modes 
of life, and is under the care of a physician with marked person- 
ality, aided by good nursing, special diet, massage, electricity, and 
the water cure — is of the greatest benefit in severe cases. 

Special symptoms must receive appropriate treatment. Hys- 
terics naturally should not associate with each other. While the 
layman cannot expect to treat hysteria, he or she may do much to 
prevent it, especially by early training. Marriage may benefit mild 
cases. Successful treatment requires unusual tact, profound knowl- 
edge of human nature, strong sympathies (but dominance of the 
patient), and enormous optimism (Edwards). 

SLEEPLESSNESS 

(Insomnia — Wakefulness) 

Natural sleep is due to fatigue associated with a comparatively 
bloodless condition of the brain, and favored by the abolition of 
sources of excitement from the brain, such as noises, light, etc. 

Causes. — The causes of sleeplessness are without number, as it 
is often merely a symptom of an unnatural state, and yet the only 
reasonable treatment consists in removing the cause in order to 
remedy the disorder. 

Among the most frequent causes are: brain work associated 
with worry ; noise ; some sort of pain or irritation produced by in- 
digestion; and a great variety of troubles, as nervousness, due to 
tea, coffee, or alcoholic drinking; nervous exhaustion: chronic con- 
stipation ; eye strain ; skin diseases : disorders of the brain : cough- 
ing; drug habits, as the use of opium and eocain: diseases of the 
heart and kidneys : and acute inflammations and injuries of all 
kinds. High altitudes and change in the hour for the principal 
meal, together with irregular times or places for sleeping, invite 
insomnia. 



SLEEPLESSNESS 623 

In infants, disorders of digestion, as colic, constipation, pain ; too 
much sleep during the day or retiring too early; an over-hearty 
supper or hunger; excitement in play before bedtime; absence of 
sufficient fresh air by day or night; overwarm covering or room; 
noises ; bright light ; cold feet ; or fatigue — all these are common 
factors in insomnia. 

Treatment.- — The cause should be corrected, if possible; it will 
often require a physician, however, to do this. Among the more 
simple remedies are the following: A hot foot bath or a warm 
(not hot) bath before bedtime, with a cold cloth on the head, will 
often procure sleep — particularly if there is heat of the head with 
a tendency toward flushing of the face. If the feet are cold and 
the head hot from mental work the use of a hot water bag at the 
feet is beneficial. The room should be cooler than by day (58° 
to 60° F. or lower), except in the case of young infants and old 
persons; an exceedingly cold room favors sleeplessness, however. 
Some hot drink on retiring is often useful in aiding sleep, as hot 
milk with nutmeg grated or malted milk, hot soup, or hot toddy 
(for the aged), or a glass of beer. 

When sleeplessness threatens, the mind must be diverted from 
the idea that one will not sleep. Reading a heavy or prosy book 
in bed (classics, as "Plutarch's Lives," etc.), or performing move- 
ments, such as deep breathing, or counting, are sometimes efficacious 
in diverting the mind from the haunting fear of insomnia. Wake- 
fulness during the middle of the night may be combated by a 
glass of hot water or one of the other drinks mentioned. 

Exercise out of doors, with avoidance of fatigue, and change 
in the activities from brain work to sports are frequently advan- 
tageous. Since insomnia is merely a symptom in many cases, e. g., 
of beginning nervous exhaustion, it behooves one to consult a physi- 
cian if other symptoms occur. 

Drugs should be the last resort, and are only permissible for 
a few nights to break up the wakeful habit. The greatest harm 
has been done by their habitual use, and they should be taken 
only under a physician's advice; but when this is not practicable, 
sodium bromid may be used with safety for a short period. Adults 



624 NERVOUS DISEASES 

may take fifteen grains two hours before retiring, and the dose should 
be repeated at bedtime, dissolving the drug in one-half glass of 
water. 

Xo drug inducing sleep should ever be taken continuously, or 
more than once or twice a week. Xo form of opium is ever per- 
missible for the relief of insomnia. 

For children — besides removal of any discoverable cause — the 
warm bath at bedtime, or, if there is fever, wrapping the child in a 
sheet wrung out in cool water with a cold cloth on the head, and 
then in a warm blanket, will usually be sufficient. Whenever wake- 
fulness results from pain of any severity, the usual remedies for 
sleeplessness fail completely. 

HEADACHE 

It is unnecessary to describe headache. The chief object should 
be to discover and remove the cause. 

Causes. — Among the more common causes are the following: 
eye strain ; disease of the nose, throat, ear and teeth ; indigestion 
and constipation ; poisons ; nervous debility ; fatigue ; anemia ; men- 
struation ; brain diseases : heat stroke ; adolescence ; cold ; circulatory 
disturbances and migraine. 

So much confidence was formerly placed in the location of pain 
in the head, as a means of diagnosis, that charts showing the sites 
of headache were hung on the walls of hospitals. The location of 
headache is often wholly misleading. The headache from eye strain 
may be either about the eyes, or in the back or top of the head, 
and the same applies to other headaches. Pain, however, in the nape 
of the neck or base of the skull, which may be more often a feeling 
of pressure, is quite characteristic of nervous prostration. In sick 
headache the pain is almos! always on one side of the head. 

The time of headache is of some importance. Headaches com- 
ing on regularly in the morning suggest disease of the nose or nasal 
cavities. 

The kind of pain does not aid diagnosis. Xeuralgic or darting 
pain may not be owing to nervous derangement but to a bad tooth, 
nasal disease, etc. Headache from disease of the womb and ovaries 



HEADACHE G25 

is a tradition, but recent study seems to discredit such a cause. Fre- 
quent headaches, lasting even a lifetime and without discoverable 
cause, may be attributed to some unknown nervous derangement. 
We will now consider in detail some of the special causes of 
headache: 

Eye Strain. — Eye strain is by far the most frequent cause of 
headache. There are no special symptoms, however, by which the 
patient or doctor can tell in any particular case that the headache 
is peculiar to eye strain. Eye strain commonly means astigmatism 
or muscle weakness. 

While the pain may be located about the eyes and come on after 
special use of the eyes, it may be in any part of the head and arise 
without any apparent relation to the use of the eyes. The writer 
had a patient who suffered from severe headaches, on Sundays 
only, which were cured by wearing glasses. Inability to use the 
eyes long for close work, twitching and inflammation of the eyelids, 
frequent styes, and flow of tears, may suggest eye strain. Xausea 
and vomiting are often produced by eye strain. But in most cases 
we have no symptom but headache and, when this is frequent, the 
eyes should always be examined by a competent oculist — not by an 
optician. 

Disease of the Nose and Throat. — Headache coming on regu- 
larly in the morning, especially about the forehead, should suggest 
nasal trouble. In persons who have had unusual discharge from 
or obstruction in the nose, this kind of headache is likely to occur. 
A discharge of thick secretion from one nostril at times is often 
characteristic. Severe headache, arising in persons with acute colds 
in the head or grippe, is likely to be due to inflammation and re- 
tention of secretion in some of the cavities in the forehead and 
face connected with the nose. This is called sinus disease. The 
headache may be constant and extreme and the patient very sick, 
perhaps with high fever and delirium. There is often much tender- 
ness when pressure is made about the eyebrows and on either side 
of the root of the nose. The pain may be in the eyes, forehead, 
or other part of the head. Much confusion and many mistakes in 
diagnosis have been made in such cases and, when headache fol- 



626 NERVOUS DISEASES 

lowing cold in the head is persistent, it is always wise to seek the 
advice of a nose and throat specialist. 

Ear Disease. — The pain usually begins in the ear, but the writer 
has seen a case in which pain from inflammation of the ear was 
referred wholly to a tooth. There may be fever, and tenderness 
on pressure behind the ear and in front of the external opening of 
the ear. 

Decayed Teeth. — A diseased tooth may cause pain in the upper 
part of the face or temple so as to appear like neuralgic headache; 
there may even be no cavity visible and none of the teeth may be 
sensitive to jarring or pressure. The teeth should always be ex- 
amined by a dentist in neuralgia about the face and head. 

It will be noted how often headache is due to head troubles. 

Indigestion — Constipation — Biliousness. — Headache is most fre- 
quent in that common form of indigestion (atony), where the food 
"lays in the stomach" and ferments. Another frequent cause is 
constipation masquerading under the name of biliousness. The 
patient can readily recognize headache from either of these causes 
by symptoms of indigestion, as nausea, coated tongue, bad taste in 
the mouth, belching of gas, feeling of weight ■ and discomfort in 
the stomach and bowels, moving spots before the eyes, and mental 
depression. In constipation the effect of a quickly acting cathartic 
is often magical — as a bottle of magnesium citrate, or four table- 
spoonfuls of castor oil, or two or three compound pills may be 
taken at bedtime. 

The meals should be light for several days and a diet may be 
allowed of cereals, crackers, toast, eggs, chops, chicken, white fish, 
a little baked potato, and buttermilk between meals, when the trouble 
points toward dyspepsia. 

Poisons. — Many chemical substances circulating in the blood 
cause headache. The headache following alcoholic excess is most 
familiar. Excess in the use of tobacco, and possibly of tea and 
coffee, may excite headache and also irregular and violent action 
of the heart or palpitation. 

Many drugs occasion headache as opium, lead, iron and nitro- 
glycerin, quinin and salicylates which also cause noises in the ears. 



HEADACHE 627 

The headache of indigestion, noted above, is supposed to be due to 
chemical poisons resulting from the fermentation and delay of 
food in the bowels. In the various fevers or infections headache 
is produced by the chemical poisons arising from the growth of the 
special causative germs. 

Headache is especially prominent in typhoid fever, and in the 
eruptive diseases, as measles, scarlet fever, and smallpox; also in 
cold in the head, grippe, and tonsillitis. In these diseases it is not 
the sole, or even the chief, symptom. However, in typhoid fever, 
headache may be the most salient symptom at first with perhaps 
a feeling of weariness, cough, occasional nosebleed, and fever. The 
presence of headache and fever should always be a warning to seek 
medical advice. 

Headache may be the main complaint in malarial fever. Head- 
ache and facial neuralgia are supposed to take the place of the 
chill and fever in malaria sometimes, and therefore to occur at a 
regular hour daily — every other day or every fourth day. Their 
connection with malaria is usually doubtful, in the absence of fever, 
but if headache is caused by malaria it will be cured by taking 
quinin. 

The headache in Bright's disease of the kidney may be asso- 
ciated with swelling of the feet and ankles, shortness of breath, 
pallor, nausea, and vomiting; or headache may be the only symp- 
tom. Headache with dizziness and stupor may develop in diabetes, 
with the passage of large quantities of urine and the presence of 
thirst. 

The escape of illuminating or coal gas into living rooms is a 
prolific cause for headache. 

Nervous Debility — Fatigue — Anemia. — We have already noted 
that in nervous prostration headache is more often a feeling of pres- 
sure or constriction in the nape of the neck or back of the head. 
This sensation may also be general throughout the head, or in the 
top of the forehead, temples, or other part. It is doubtful if head- 
ache is common in anemia alone, but it is said to occur in that 
form in young women and to be relieved by lying down, which also 
benefits the headache of nervous prostration. Fatigue, hunger, and 



628 NERVOUS DISEASES 

overwork, especially in ill-ventilated rooms, are commonly recog- 
nized causes of headache. 

Menstruation. — This is often preceded or followed by headache. 

Brain Diseases. — In tumor or syphilis of the brain the headache 
is usually so violent as to prevent sleep, and there is often vomiting. 
In syphilis the pain occurs more often at night. The headache may 
be general, or on one side or part of the head. The constancy and 
severity of the headache, continuous for weeks, and the presence of 
slow pulse, paralysis of some part of the body, convulsions and stu- 
por are characteristic of brain tumors. There may, however, be 
intervals of freedom from pain lasting weeks or months, in brain 
tumor. In meningitis there are similar symptoms, but the disease 
comes on rapidly, fever is marked, and the head is drawn back. 

Miscellaneous Causes. — Heat Stroke. — Persons who have had 
heat stroke or who have only been exposed to excessive heat are 
liable to headache. 

Concussion of the Brain. — A blow on the head with concussion of 
the brain will be followed by headache. The patient should stay in 
bed in a dark room with an icebag on the head. 

Adolescence. — During adolescence, for some unknown reason, 
headache is common. 

Headache from Cold. — There is a kind of severe persistent head- 
ache felt chiefly in the back of the head, neck and shoulders asso- 
ciated with sensitive lumps in the muscles of the back of the neck, 
just below the skull, while some are felt in the back of the skull 
itself and may be very tender. The condition is thought to be due 
to exposure to cold ; it may be cured by massage. 

Circulatory Disturbances. — In some persons changes in the caliber 
of the blood vessels caused by nervous derangement and shown by a 
red face and red blotches on the skin in various parts of the body, 
will produce headache. 

MIGRAINE 
(Sick Headache) 

This, in most instances, is a distinct form of nervous disease. 
It is a functional mental disorder, like epilepsy, and in ninety per 



MIGRAINE 629 

cent, of the cases is inherited. This does not mean that the parents 
have suffered from migraine necessarily, but from some nervous or 
mental disease. 

Migraine is a peculiar, one-sided headache which takes the form 
of severe periodic attacks at more or less regular intervals. It may 
occur at a certain hour and often on a special day of each week, 
fortnight, or month, and often disappears at a certain hour. The 
disorder generally persists for years. Thirty per cent, of cases 
begin between the ages of five and ten ; forty per cent, of cases before 
thirty. Therefore attacks of apparent sick headache which begin 
after thirty are probably some other disease. 

When the disease arises in childhood it may cease at the begin- 
ning of adult life, but often continues to the age of forty-five to fifty 
in men, and the period of "change of life" in women. It is a little 
more frequent in women. 

Causes. — The cause of migraine is unknown. When the tendency 
exists various other disorders may excite attacks. Among such con- 
ditions, which may bring on sick headaches, are : fatigue, eye strain, 
special articles of diet, indigestion, constipation, sexual abuse, alco- 
holic excess, diseases of the female sexual organs, and perhaps large 
tonsils and adenoids. Unlike most of the headaches described, due 
to some special cause, it is often impossible to cure migraine by the 
removal of the supposed causative conditions just mentioned — 
although it may sometimes be done. 

Symptoms. — There may be some warning of the approach of a 
sick headache. The patient will feel unusually well the day previous, 
or there may, on the other hand, be mental depression and weariness ; 
occasionally an aura or immediate warning is perceived for ten or 
fifteen minutes before the attack. Thus light or dark spots appear 
before the eyes, or there may be dizziness, buzzing in the ears, or 
blurring of sight. Then the pain begins in a spot about one eye, 
temple, or forehead, and may spread all over the side of the head, 
and rarely to the neck and arm. The chief feature consists in the 
headache being confined to one side of the head. 

The headache is violent and boring and is aggravated by move- 
ment, noise, and light. The patient must lie down in a dark, quiet 



630 NEEVOUS DISEASES 

room and is incapacitated for all duties. Nausea and vomiting 
appear toward the end of the attack: first bile and then food are 
brought up, hence they are sometimes called "bilious headaches.' ' 

Sick headaches last twelve hours, on the average, or from a few 
hours to three days in severe cases ; the duration is about the same in 
any individual case. Relief is usually experienced at a certain hour 
after free vomiting, and often there is then a feeling of well-being 
and enormous appetite. Patients are well between attacks, unless 
they recur frequently. Very rarely does migraine become trans- 
formed into some severe form of organic nervous disorder. 

Diagnosis. — "Sick headaches" beginning in childhood with a his- 
tory of nervous inheritance are practically always migraine ; those be- 
ginning after thirty should be viewed with suspicion and more often 
are secondary to some other disease. But migraine frequently does 
not follow the above description — the warnings are generally absent ; 
there is simply one-sided headache and vomiting, or headache with- 
out vomiting, or even attacks of vomiting without headache. If 
diseases were typical doctors would be superfluous and one could use 
a book instead. 

Treatment. — Any article of food provoking an attack should 
naturally be avoided. The writer has a patient in whom cocoanut 
in any form invariably precipitates an attack. All the conditions 
mentioned as known causes should be removed if possible — not being 
able to dispel the hereditary cause, we are often unsuccessful in cure. 

At the first warning a tablet of nitroglycerin, containing one- 
hundredth of a grain, may ward off an attack ; it may be repeated 
once or twice, at fifteen minute intervals if it affords relief. A 
quickly acting cathartic, as a bottle of magnesium citrate, or a table- 
spoonful of Epsom salts in a whole glass of water, is beneficial at the 
beginning of the attack. The patient should lie down in a quiet, 
dark room, with an icebag or cold cloth on his head and hot water 
bottle at his feet, while mustard paste (flour, four parts — mustard, 
one part), between two pieces of old cotton cloth, should be applied 
to the back of the neck and over the stomach. Menthol cologne or a 
menthol pencil applied to the forehead, or the drinking of hot strong 
tea with lemon juice, may be of service. Fluidextract of cannabis 



MIGRAINE 631 

indica may be taken in two drop doses every half hour until relief is 
obtained — not using over ten doses. 

To permanently prevent the return of the disease one of two drugs 
is employed : strontium bromid in ten grain doses three times daily 
after meals in one-half glass of water, or one-quarter of a grain of 
extract of cannabis indica three times daily in pills, after eating. 
Either must be taken for weeks or months. 



CHAPTER VIII 
NERVOUS DISEASES (Continued) 

Hiccough. Facial paralysis. Neuralgia. Sciatica. Convulsions in chil- 
dren. Epilepsy. Delirium tremens. Chronic alcoholism or steady 
drinking. 

HICCOUGH 

The noise produced in hiccough is caused by sudden sucking in 
of air into the throat, by means of violent and repeated contractions 
of the diaphragm — the great muscular partition at the bottom of the 
chest, separating it from the organs in the abdomen. While this 
curious disorder usually lasts but a short time it sometimes persists 
for days or weeks and becomes an alarming and occasionally a fatal 
malady. 

Causes. — Frequently there is no apparent cause, as it appears in 
persons in seemingly perfect health. Irritation of the mouth and 
throat caused by hot drinks, pepper, a strong pipe, etc., are frequent 
sources of the trouble. 

Indigestion is another common cause, particularly in children. 
Excitement and some nervous diseases (particularly epilepsy, hysteria 
and shock) induce it. In various inflammations of abdominal organs 
and in typhoid fever it is common ; also in gout, diabetes, and in 
kidney disease. 

Treatment. — Among the more simple and effective remedies are 
holding ice in the mouth or drinking cold water, dragging out the 
tongue, and tickling the nose with a straw until one sneezes several 
times. Holding the breath or taking deep breaths, and taking locally 
stimulating drinks, as a teaspoonful of straight brandy or whisky, 
or a teaspoonful of salt in lemon juice, will sometimes arrest hic- 
cough. A most effectual remedy consists of stopping up both ears 

632 



FACIAL PARALYSIS 633 

with the tip of one finger of each hand while one drinks from a cup 
held by another person. 

Swallowing a little Jamaica ginger in water will sometimes afford 
relief. Washing out the stomach or the use of an emetic or cathartic, 
or both, are of benefit if there is indigestion. The application of a 
tight binder about the chest with the head held forward may check 
the trouble, or the use of mustard and flour poultice to the neck and 
pit of the stomach. In the cases which resist these simple measures, 
it will be necessary to procure medical aid. A teaspoonful of com- 
pound spirit of ether, or one-half teaspoonful of spirit of camphor, 
in a little ice water, will often prove successful, and may be repeated 
every hour, for three doses if necessary. In severe cases a doctor 
will have to inject morphin freely. 

FACIAL PARALYSIS 

Causes. — This is a common disorder, frequently due to exposure 
to cold, as, for example, from cold air blowing on one side of the 
face in driving or while sleeping near an open window. Disease of 
the ear is a cause, especially in children; also injuries about the ear 
and tumors in this region ; and syphilis is also a cause. One theory 
is that facial paralysis may be due to a microorganism setting up an 
inflammation of the facial nerve. 

Among the less common causes which do not concern us so much 
here (as they require medical skill for their determination) are 
diseases of the brain in which other parts of the body may also be 
paralyzed, and in which the general health may be disturbed in 
many ways. 

Symptoms. — The patient may have a cold in the nose or throat, 
or both, owing to the same exposure which produces the facial 
paralysis ; however this is not always the case. The paralysis comes 
on rapidly, usually with little pain, although there may be earache. 
The patient may discover it on looking in a mirror, or on trying to 
eat, talk, or whistle. 

The face is smooth and expressionless on the paralyzed side; the 
eye cannot be closed on that side and weeps; the mouth is drawn 
over to the well side, and saliva may flow from it. Whistling becomes 



634 NERVOUS DISEASES 

impossible; eating is interfered with, and the food collects in the 
cheek of the paralyzed side. When the patient attempts to laugh, 
the paralysis becomes very noticeable, for the face is wrinkled on 
the sound side, but motionless on the paralyzed side. Speech is 
somewhat difficult. Wrinkles disappear from the forehead on the 
paralyzed side, and cannot be made to appear at will. The lower 
eyelid and corner of the mouth droop on the paralyzed side. 

There may be a peculiar taste at first, and later there may be 
some loss of taste in the tongua There may be some swelling of the 
face on the paralyzed side in the beginning of the trouble. Deafness 
sometimes accompanies facial paralysis, and is commonly a sign of 
existing ear disease. 

The facial paralysis following exposure to cold usually disappears 
with complete recovery in from two to six weeks. Persons have 
been known to have several attacks. 

Treatment. — Hot applications should be made about the ear for 
the first few days. If there is running from the ear, or earache, an 
aurist should be consulted. The most valuable measures aiding 
recovery are electricity and massage, which must be managed by a 
physician. Some cases may run on for six or eight months, and then 
eventually recover. In other patients a certain amount of altera- 
tion in the facial expression may permanently persist. 

NEURALGIA 

Neuralgia means pain in a nerve or nerves. Theoretically there 
is no change of structure in the nerve in neuralgia, but practically 
it is occasionally impossible for even a physician to distinguish 
inflammation of a nerve (or neuritis) from neuralgia. 

Causes.— Neuralgia occurs more frequently in those inheriting a 
weak nervous system, in the overworked and underslept, the anxious, 
nervous, excitable person. It is rare in childhood, and many varie- 
ties, as facial neuralgia, are more common in women, while sciatica 
attacks men more frequently. 

A "run-down" condition favors the disease, especially when com- 
bined with poor blood. Exposure to cold, bad teeth, overindulgence 
in alcohol and in tobacco, rheumatism, gout, kidney disease, diabetes. 



NEUKALGIA 635 

and lead poisoning are among the exciting causes. It is more apt 
to attack women during pregnancy and the "change of life." 

Symptoms. — Neuralgia may begin suddenly. More often there 
are some peculiar feelings, as a sensation of cold or prickling, before 
the pain commences. The pain is of a sharp, darting, shooting, 
stabbing, or burning nature, with intervals of a second or a few 
minutes when the patient is free from suffering. 

It occurs more often on one side of the face or chest. The skin 
over the painful region is rarely swollen, and hot or cold, but almost 
invariably it is very tender. When pain attacks the eye tears may 
flow; when the pain is referred to the teeth saliva may flow freely. 
Neuralgia about the head rarely leads to falling or whitening of 
the hair. Twitching or spasms of the muscles in the painful area 
may be present. Painful spots along the course of the nerve which 
gives rise to the pain are a peculiar feature of neuralgia. 

Attacks of neuralgia may subside without treatment in time, but 
are likely to last from one to several hours, and to return at regular 
or irregular intervals of long or short duration. 

Diagnosis. — Neuralgia sometimes attacks the back of the head 
and neck, or the shoulder and upper arm, when the pain resembles 
that of rheumatism or of an injury to the shoulder. 

Neuralgic pains of one side of the chest are not rare. They are 
much aggravated by motion, deep breathing, or coughing. They 
may resemble the pains of pleurisy, but there is usually no fever 
or cough ; still, examination of the chest by a physician is essential to 
rule out the latter disease. Neuralgia in the left side of the chest, 
in the region of the heart, is common in women and is frequently 
the cause of much anxiety on account of supposed heart disease. 
Unless other symptoms of heart disease are present, or unless there 
is fever, such pain is much more apt to be neuralgia and is not 
serious. 

Pain in the chest resembling neuralgia may be produced by many 
other conditions, and, therefore, a careful medical examination is 
always desirable. Neuralgia of the chest is seen more often in thin, 
nervous women. In this affection tender spots may be discovered near 
the spine and breastbone, and midway between these points. 



636 NERVOUS DISEASES 

Neuralgia of the spine, with tender spots along its course, and 
pain in the neck, or in the middle or small part of the back, is often 
present in nervous women, and in those suffering from railway 
accident. Pain in the very lowest end of the spine, which is aggra- 
vated by the sitting position, is also common in women. Occasionally 
persons suffer from neuralgia in the heel and sole of the foot. 

Complications. — An eruption on the skin, known as shingles, may 
be associated with neuralgias of the chest. After a few hours or 
days, or even a longer period, a red, tender spot appears, and upon 
this a group of small blisters occurs. When the eruption disappears 
the pain usually subsides, but may continue indefinitely, and there 
is great tenderness of touch. Shingles may be seen on the head, 
forehead, face, upper arms, shoulder, buttock, and thigh, accom- 
panied with severe pain. It usually attacks only one side of the body. 

The eruption should be well dusted over with powdered boric 
acid, being careful not to break the blisters. Then gauze, covered 
well with boric acid, should be laid on the eruption and held in 
place by a bandage about the chest. When the eruption is very 
painful zinc ointment, containing twenty grains of menthol to the 
ounce, may be spread on the eruption and covered with sterile 
gauze and bandage. 

Treatment of Neuralgia in General. — Prevention is better than 
cure. Wholesome, nourishing food, exercise out of doors, change of 
air and scene, cold baths, and sea bathing are valuable in preventing 
neuralgia in susceptible persons. The same measures will be found 
valuable in the treatment of neuralgia, with the possible exception 
of cold baths. 

Such remedies as the analgesic ointment in tubes (baume anal- 
gesique), menthol pencil, or chloroform and alcohol — each one ounce 
— in which sixty grains of menthol are dissolved may be applied 
externally and covered with oil silk. Heat in the form of a hot water 
bag or poultice is often of great benefit. A two grain quinin pill 
may be taken hourly during the attack. 

Exposure to cold, mental excitement, and movement aggravate 
the pain. Pain is a vague and uncertain symptom, and may be 
felt in a spot distant from the real source of disease, so that it is 



NEURALGIA 637 

not safe for a layman to call his pain neuralgia nntil he has re- 
ceived a proper medical examination. There are many other reme- 
dies which can only be employed by the physician, including elec- 
tricity, drugs, and surgical measures, and the neuralgic patient should 
seek his services at the earliest moment. 

Facial Neuralgia 

{Tic douloureux) 

This is the most common form in women. The pain may be felt 
in the forehead, eye, and nose, on one side of the face, with a spot of 
tenderness just above the eye. The eye is often bloodshot and the 
tears flow, or the pain is felt between the eye and mouth, with spots 
of tenderness on the side of the nose, below the eye, and along the line 
of the gum of the upper jaw on one side of the face. Frequently 
the pain attacks the temple, ear, lower jaw, teeth, and tongue, with a 
tender spot in front of the ear; there is increased pain in chewing 
and speaking, and saliva runs from the mouth. Neuralgia of the 
face occasionally causes severe pain, and continues obstinately for a 
long period, especially in those with inherited tendencies and in the 
elderly. 

Sciatica 

Sciatica is a neuralgia or inflammation of the sciatic nerve 
which extends from the upper middle part of the back of the thigh 
down to the foot. 

Causes. — It is occasioned by exposure to cold or wet, by lifting, 
and in women, may be due to some disease in the neighborhood of the 
womb or to injury sustained in childbirth. It may also be due to 
disease of the spine. Rheumatism is a common cause. 

Symptoms. — -It may come on suddenly, or gradually, beginning 
with pain in the small part of the back. The true pain of sciatica 
starts in the middle of the upper fleshy part of the back of the thigh, 
and extends down the middle of the back of the limb, even to the 
foot ; there are tender spots along this course, especially in the upper 
and middle portion of the back of the thigh. 

The pain is generally intense — worse at night and on walking. 



638 NERVOUS DISEASES 

It is burning or boring in character, but at the beginning may be 
felt only after exercise, or when the leg is held in certain positions. 
Walking becomes difficult (or impossible), even if the weight is 
borne on the toes with the knee bent. There are sometimes cramps, 
spasms, and wasting of the muscles in the disabled limb. The patient 
usually is compelled to remain in bed, and the disease may last 
months, with occasional improvement and return of the trouble. 

Sciatica is frequently mistaken for sprain of the back which is 
quickly relieved by strapping with surgeon's adhesive plaster. A 
thorough examination by a medical man is demanded to eliminate 
local disease, as of the spine or hip. and. in women, of special troubles 
which may occasion the sciatica. 

Treatment.- — Eest in bed with the application of hot water bags 
to the back of the thigh may be employed: wrapping the limb in 
cotton batting and bandaging are of service. A blister, cut one and 
one-half inehe- square, may be applied for a few minutes over the 
seat of the pain at the upper pan of the back of the thigh, or iodin 
may be painted on the same spot over a surface as large as a silver 
dollar until the skin is almost black, and either of these may insure 
relief in mild cases, if used at the very beginning of the trouble. A 
host of remedies is at the command of the physician, and a patient 
is unfortunate, indeed, who cannot procure medical aid to relieve 
Lis suffering, though many cases are very intractable. 

CONVULSIONS IN CHILDREN 

Symptoms. — Convulsions may begin with squinting of the eyes, 
restlessness, starting or crying out in sleep, grinding the teeth, bend- 
ing the thumbs, or slight twitching of the muscles of the face or 
limbs. Such signs should serve as a warning, particularly if the 
child is feverish, and should lead one to bathe the patient immediately 
with cool water as described below. 

The fit may begin with a cry or choking sound : the body stiffens 
and is arched forward, while the head and neck are bent rigidly 
backward ; the belly may be arched upward so that the child rests 
on the back : his head and on his heels. The eyes are fixed, staring, 
squinting or rolled up. but sightless ; the child neither sees, feels. 



CONVULSIONS IN CHILDREN 639 

nor hears — he is wholly unconscious. The face becomes blue, the 
hands are clenched, and then the body and limbs begin to jerk and 
twitch, the arms and legs being alternately bent and straightened. 
The breathing is rapid and noisy, there is grinding of the teeth and 
frothing at the mouth ; sometimes the tongue is bitten. 

The whole attack may last but a moment, and there may be no 
more, or the attack may last for several minutes, or, rarely, hours, 
or there may frequently be repeated attacks. If the immediate 
cause, as fever, can at once be removed, there is little probability 
of a return of the fits. The child, after the convulsions, acts be- 
wildered and begins to cry; he returns to consciousness, or falls to 
sleep or into a stupor, or, very rarely, dies in the fit. 

Treatment. — The child should be placed in a bath a little warmer 
than blood heat (105° F.), but not hot, with a cold cloth on his head, 
and kept under water to the neck for ten minutes. Then he should 
be removed and wrapped warmly in blankets. Great damage has 
frequently been done to children by exposing them unduly, or burn- 
ing them by water which is too hot, in the excitement of the moment. 
When a warm bath is not obtainable one should dip a towel into a 
quart of warm water (in which is stirred a tablespoonful of mustard), 
wring it out, and wrap it about the child's body, which is then cov- 
ered with blankets and allowed to remain ten or fifteen minutes in 
this pack. 

When the child is conscious and can swallow, a teaspoonful of 
syrup of ipecac should be given to empty the stomach. Just as 
soon as the child is removed from the bath, an injection of warm 
soapsuds, to move the bowels, is advisable. Immediately afterward 
about one tablespoonful of thin boiled starch and water containing 
from three to five grains of chloral (or, if the child is over two years 
of age, five to ten grains of chloral) should be injected into the bowel. 
The child should be made to retain it by holding a towel over the 
outlet of the bowel. It is wise also to open the bowels by giving one 
grain of calomel (or two grains, if over one year of age), dropped 
on the tongue, or mixed with a little sugar and water in a teaspoon. 

If the child has fever (the temperature should always be taken 
if possible), the treatment is different from the above. He should 



640 NERVOUS DISEASES 

not be given the warm bath, but a cold cloth should be continually 
on the head, and the entire naked body sponged frequently with 
cool, not cold, water (70° F.), rubbing the skin dry covering the 
patient lightly, and placing a hot water bottle at the feet. It is well 
to use the bowel injection and chloral in fever cases, but not the 
emetic. 

The milk should be largely diluted with water, if the patient is 
a bottle-fed baby, for some time after the attack. The condition 
which has caused the convulsion should be investigated by a physi- 
cian, and removed if possible. Children of school age should be kept 
away from school indefinitely after a convulsive seizure. 

Causes.. — Children born of nervously weak or alcoholic parents, or 
infants weakened by rickets or some exhausting disease, as diarrhea, 
are more liable to spasms — especially under the age of two. 

Among the more common immediate causes of convulsions are: 
indigestion, teething, the onset of fevers of any kind (where the 
chills in an adult are often replaced in children by convulsions), as 
grippe, measles, scarlet fever, pneumonia, malaria, tonsillitis, diph- 
theria, and chickenpox. In these bacterial diseases it is the poison 
produced by the germs which irritates the brain rather than the mere 
increase of temperature in the fever. Eaisins or orange peel swal- 
lowed by young children have not infrequently caused convulsions. 

Among the less frequent causes are : worms, earache, heart disease, 
whooping-cough, disease of the brain or spinal cord, severe and pro- 
longed diarrhea, fright, anger, foreign bodies in nose or ear, pain, 
constipation, tight foreskin, and hot weather. 

Spasms occurring soon after a difficult childbirth, especially 
when instruments were used, indicate a probability that injury of 
the brain is the cause, and the result is uncertain. 

When spasms appear first as twitching of certain muscles, and 
increase in gravity and frequency as time goes on — particularly if 
the child is backward, awkward, or has a head of unusual size or shape 
— there is a likelihood of epilepsy (See below). 

Outlook.' — Infants, figuratively speaking, are bundles of sensitive 
nerves and centers, as yet unused to resist slight sources of irritation, 
so that in conditions when adults have chills, fever, or delirium, 



EPILEPSY 641 

babies have convulsions. These, as we have seen, however, are rarely 
fatal in themselves, although terrifying to the anxious onlooker. 
Indigestible food, as bananas and corned beef, may cause the most 
severe attacks in young babies. 

Convulsions occurring in children with high fever do not usually 
return when the fever is reduced, so that when teething and indiges- 
tion are at the bottom of the attack, the measures recommended will 
usually prevent a return of the trouble. It is only when convulsions 
are frequent and persistent that the outlook becomes serious and the 
danger of epilepsy or other organic disease of the brain threatens. 
Removal of the cause will generally effect a permanent cure of 

convulsions. 

EPILEPSY 

Diagnosis. — The only apparent difference between epilepsy and 
accidental or occasional convulsions in children is one of duration. 
The attacks are similar — one cannot distinguish between them — but 
in epilepsy the fits are repeated and the condition is chronic. 

Forms.^There are two kinds of epilepsy we need note — a severe 
form with insensibility and spasms; a milder form with transient 
loss of consciousness without spasms. 

Symptoms of the Severe Form. — There are three stages in the 
attack : 

( 1 ) The patient may turn around rapidly, or even run swiftly ; 
more often a terrible cry or low gurgling groan is emitted, and the 
patient falls to the ground unconscious. The body is stiff and arched 
upward, with the head thrown back or to one side, or the body is bent 
sidewise. The face is pale at first, but quickly becomes dark or bluish, 
the jaws are rigidly set, the legs are outstretched, but the arms are 
bent at the elbow with the fingers tightly clenched in the palms. 
This is the rigid stage, and lasts but fifteen to thirty seconds. 

(2) This is the convulsive stage. The spasms begin; the limbs 
are jerked violently; the face is contorted and working. The eyes 
are wide open and rolling, the pupils dilated, and the whites show- 
ing. The jaw may be firmly set and the tongue or lips bitten, or 
the mouth may be open with the lips flapping loosely in breathing, 
and the mouth covered with froth which may be bloody. Sometimes 



642 NERVOUS DISEASES 

the urine escapes, and less often the contents of the bowels. The 
fit rarely lasts more than one to three minutes. 

(3) The patient gradually becomes relaxed and quiet, and may 
recover after a variable time. Sometimes he comes to himself very 
soon in a dazed and bewildered state at first, and suffers from a 
dull headache; at other times the patient remains unconscious, with 
red face and noisy breathing — in a stupor, from which he may be 
aroused after a time, or may not awake, if left alone, for hours. l$o 
memory of the fit is retained. 

More often the attacks recur every two or three weeks. Some- 
times they happen as often as a hundred times in one day, and 
occasionally only once in a year or two. They begin more commonly 
in youth. Following an attack a patient may do violent acts of 
which he is unconscious, he may have pains in muscles, exhaustion, 
paralysis, or difficulty of speech, or remain in a dull, despondent, or 
trancelike state ; sometimes he feels particularly well. In severe and 
fatal cases, the fits occur in rapid succession without any intervals of 
consciousness. Both sexes are equally liable to epilepsy. 

The severe attacks of epilepsy often give warning of their com- 
ing. Thus, for a few seconds before a fit, a person may have peculiar 
sensations, as a tickling or tingling of the hand, or pressure in the 
region of the stomach, or strange feeling over the heart, which seems 
to rise and envelop the head. In others, there may be flashes of light, 
odd noises or voices, peculiar odors or tastes, or a feeling of terror 
or strangeness preceding the attack. In the majority there is, how- 
ever, no distinct warning or "aura," as it is called. 

Attacks may occur at any time of day or night and, if at night, 
they may pass unnoticed for years, although if the bed is wet with 
urine and there is any injury to the tongue on waking, there is a 
strong probability that a fit occurred during the night. Hysterical 
attacks in girls or young women are often mistaken for epilepsy. 

Symptoms of Epilepsy without Spasms (Petit mat). — In this 
form of epilepsy there is momentary unconsciousness, but the patient 
does not have spasms. Sometimes it is a mere interruption in his 
occupation. He becomes suddenly pale, the eyes are fixed, and he 
stops talking, eating, playing the piano or cards, or dressing, only 



EPILEPSY 643 

to continue in a few moments where he left off. He may be walking 
when attacked and continue mechanically, and come to himself, find- 
ing that he has been unconscious. A glass or spoon or other object 
which he may have been holding at the time, usually falls from the 
hand. 

There may be some confusion in speaking or dizziness after the 
attack, or the patient may perform some common act unknowingly, 
such as to partially undress, or even to do acts of violence. There 
are many varieties of this milder kind of epilepsy, but it usually 
ends in the severe form with fits, as described above. 

Fainting is most likely to be confused with the mild form of 
epilepsy, but in fainting the patient usually falls and the pulse is 
feeble or imperceptible, while in this variety of epilepsy the patient 
does not generally fall and there is a history of similar attacks and 
the pulse is not much affected. In some cases patients do fall uncon- 
scious in petit mal, but do not have convulsions. 

Treatment. — During the fit one should loosen the clothing about 
the neck and body, see that the patient is kept lying down and not 
injuring himself, and also prevent his tongue from being bitten by 
holding a piece of rubber, a fold of towel, or cork, between the teeth. 
If a small body like a rubber stopper, an ink eraser, or a cork be 
used, a string must be tied to it for safety. This is usually all that is 
required unless the fit is longer than usual, when the physician may 
find it necessary to resort to powerful remedies best administered by 
himself. 

The general treatment consists in abstinence from meat and 
from salt, in an outdoor life, and in the use of bromids. In children 
education and discipline should not, however, be relaxed unless con- 
vulsions are frequent and severe, when treatment in a home for 
epileptics is advisable. 

Sodium bromid may be given to advantage, until a physician's 
advice be procured, stopping it for a time if such symptoms as con- 
stant drowsiness, coated tongue, or pain in the stomach and bowels 
develop. Sixty grains daily is an average dose for an adult, and it 
should be given diluted with two glasses of water (better soda water 
or Vichy), in a single dose, four to six hours before the expected 



644 NERVOUS DISEASES 

time of attack. Laxatives must be freely used, such as rhubarb and 
soda. 

Each case must be carefully studied by a physician, as it may 
be possible to discover some cause and remove it and so cure the 
disease, and the treatment should only be pursued under such guid- 
ance. Irritation in any part of the body may be such a cause. 
Thus, the correction of astigmatism or strain of the eye muscles; 
operation or local treatment of obstructions and catarrh in the nose, 
adenoids, and tonsils; the extraction of decayed teeth; the expulsion 
of worms ; the cure of digestive disorders, constipation, or diarrhea ; 
circumcision for a tight foreskin ; and the remedying of local troubles 
in any part of the body may lead to an arrest of epilepsy. Marriage 
of an epileptic should be absolutely forbidden. 

Localized spasms or convulsions of the face, one arm or leg, with- 
out unconsciousness (jacksonian epilepsy), frequently result from 
injuries, inflammation (meningitis), and tumors of the brain. The 
spasm may at first be limited to a single group of muscles, as of the 
jaw, toes, and thumb, and slowly extend to the whole face or limb. 
A large proportion of these cases is cured by operations on the head, 
but such are not usually advisable in ordinary epilepsy. 

Causes. — Epilepsy begins commonly in youth. It is not infre- 
quent for a child to have convulsions between the ages of four and 
six, and for epilepsy to appear in about the tenth year. It often 
begins in females at the menstrual period, and occurs thereafter more 
frequently at these times. Heredity is the commonest cause; about 
one-third of the cases show nervous disease — not usually epilepsy — 
in the parents, such as neuralgia, hysteria, insanity, or "nervousness" 
in some form, but most of all, alcoholism. Disease of the lungs in the 
parents seems to be a predisposing factor. 

Among the more immediate causes of convulsions besides those 
mentioned above are: steady drinking, exhaustion or poor state of 
the blood (anemia), injury, fevers, fright, and indigestible food, some 
diseases of the sexual organs, and any local cause of irritation. 

Outlook.- — Epilepsy is usually chronic, and may continue perma- 
nently; life is apt to be shortened thereby. In early life the pros- 
pects of recovery are much brighter, but the outlook is poorer in 



DELIRIUM TREMENS 645 

long-continued attacks and in grown persons. Epilepsy, beginning 
after thirty, is apt to be merely a symptom of brain disease (syphilis) 
and offers hope of cure. There is little probability of death in the 
fit, unless through the patient's accidentally falling into fire or water, 
or suffering injury in the fall, and occasionally being smothered from 
lying on the face, as when attacks occur in bed. 

Epileptic subjects are often peculiar, irritable, and excitable, 
or dull, and may become mentally deficient in time. There are 
many marked exceptions to this rule, and some of the strongest 
characters in all history have been epileptics, viz. : Mahomet, St. 
Paul, Peter the Great, Napoleon, and Julius Csesar. Some cases are 
entirely cured, and the greatest benefit has been obtained in colonies 
for epileptics which have been established in some of our United 
States. 

DELIRIUM TREMENS 

("The Horrors') 

Delirium tremens does not occur in those given to occasional sprees 
of drinking, even if prolonged, but in the habitual heavy drinkers (on 
the average, after a period of eight years), and is brought on by an 
unusual excess in drinking, failure of digestion, or by some nervous 
shock, as happens when the person suffers from bodily injury, as a 
broken leg, or an acute disease (in seventy per cent, of cases) espe- 
cially pneumonia and erysipelas. 

Symptoms. — The attack begins with sleeplessness, depression, and 
restlessness for a day or two, and then the patient experiences a 
mental change. He talks continually in a rambling, disconnected 
manner, and is in constant motion, wanting to go out to attend to 
this or that matter, and is commonly filled with fear on account of 
objects which he imagines he sees — such as rats, snakes, and monsters, 
all of which drive him into such a state of terror that he is con- 
tinually desiring to escape, and may try to jump out of the window or 
attempt suicide. There are generally some fever, a weak and rapid 
pulse, muscular weakness, and trembling of the hands and tongue; 
the skin is flushed and covered with sweat. 

After three or four days the patient will secure a good sleep, which 



646 NERVOUS DISEASES 

is usually the favorable turning point of the disorder, when rapid 
improvement follows. In fatal cases the ravings, sleeplessness, and 
restlessness persist, while the prostration and weakness of the pulse 
increase until the patient dies of heart failure. As many as seventeen 
attacks have occurred in one person. 

Kecovery is the rule in uncomplicated attacks, but the average 
death rate is fifteen to twenty per cent, and when the subject is weak 
or old, or the delirium is complicated with an acute disease, as pneu- 
monia, the mortality is very high. 

Treatment. — The patient must be watched every minute, con- 
fined to a room, and better, to bed. The room should be darkened. 
The patient should be secured by fastening the wrists and ankles to 
the side of the bed, while a sheet, folded eighteen inches wide, is 
passed over the body and made fast to the sides of the bed. In 
addition it may be necessary to use a sheet which is passed across 
the patient's back while the ends are brought upward through the 
armpits and fastened to the head of the bed. 

The essentials in treatment are elimination by cathartics, drinking 
of fluids, bathing, stimulation by drugs, good feeding, and cold 
applications. The old idea of overdosing the patient with drugs to 
make him sleep is now considered bad treatment, as the disease is 
usually self-limited to five days, when recovery can be expected in 
uncomplicated cases. To begin with the subject should be given four 
compound cathartic pills ; or five grains of calomel followed in six 
hours by a bottle of magnesium citrate. Then the drinking, during 
the first day, of three quarts of hot water or iced Vichy or soda 
water should be encouraged, or weak lemonade in which is dissolved 
a teapsoonful of cream of tartar to the quart. Whisky may be given 
to the amount of a tablespoonful in a glass of soda water every two 
hours for the first twenty-four hours, but after this it should be 
stopped and no form of alcohol should be allowed. 

For the first twelve hours no food should be taken by the patient, 
but after this he should be fed every two hours with one of the follow- 
ing: a glass of buttermilk, or rich milk diluted with an equal amount 
of soda water, Vichy or Apollinaris water, a glass of hot tea or 
coffee with a great deal of cream, egg nog, or strong broth well 



CHRONIC ALCOHOLISM 647 

seasoned. In addition, ten drops of tincture of nux vomica should 
be given in a glass of water every three hours. 

For procuring sleep nothing is better than the use of cold water 
externally. The patient should lie naked on a blanket over a rubber 
sheet. He should have cold water dashed on him by means of a 
large sponge and be rubbed over with a coarse towel until warm 
and dry, and then the same process should be repeated once or 
twice and the patient put to bed with a hot water bag at his feet. 
This treatment, with a glass of hot milk, will usually produce sleep, 
and may be carried out once or twice daily, even with the complica- 
tion of pneumonia. If sleep cannot be thus obtained a dose of one 
teaspoonful of paraldehyd, in two tablespoonfuls of whisky in water, 
may be given and repeated in one or two hours if necessary. 

Sleep cannot readily be procured until the end of the third or 
fourth day and it is well not to begin to employ drugs for this 
purpose until that time or until there are signs of exhaustion. Many 
drugs, as bromids, chloral, morphin, and hyoscin, are used by doc- 
tors, but leading authorities believe that while cases, deprived of 
alcohol and sleeping drugs, may prove more violent, the attack is 
shorter and recovery quicker without them. 

A physician's services are always desirable, particularly to dis- 
cover and treat any underlying and complicating condition, as 
pneumonia, broken rib, or other injury, to judge whether the pa- 
tient's general condition warrants the use of such powerful remedies 
as are sometimes required, and to manage the mental aspect of the 
case. 

CHRONIC ALCOHOLISM 

{Steady Drinking) 

The steady drinker tends to lay on fat; his intellect becomes 
less acute, and he is irritable, depressed, anxious, restless, forgetful, 
and dull, especially in the morning. He becomes careless about his 
person and habits, and often lies unintentionally. The judgment 
may become defective, and the mind is sometimes weak. Many ex- 
ceptions occur in heavy, habitual drinkers who preserve a high 
degree of mental ability for some years. 



648 NERVOUS DISEASES 

Epilepsy is sometimes a result. Chronic catarrhal inflammation 
of the stomach is one of the commonest effects of alcoholism, shown 
by a coated tongue, bad breath, and sinking feeling in the stomach, 
in the morning, and nausea or vomiting. The small veins on the 
face enlarge, producing a characteristic appearance — namely, the 
red nose and cheeks. There is trembling of the hands, lips, and 
tongue and the eyes are watery. Inflammation of the nerves, espe- 
cially in the legs, gives rise to pains, numbness, and, frequently, 
loss of strength. The heart and blood vessels become diseased. The 
vessels become brittle and are apt to break, occasioning apoplexy. 
Disease of the kidneys often accompanies the change in the blood 
vessels and heart. The liver is frequently attacked, and enlargement 
followed by fatal contraction results. 

Consumption is much more common in alcoholic persons. The 
children of alcoholic parents are more prone to suffer from various 
nervous diseases, such as neurasthenia, hysteria, chorea, epilepsy, 
insanity, idiocy, and also from rheumatism and gout. Occasional 
excess in drinking is much less apt to produce permanent injury than 
habitual immoderate drinking. 

Individuals differ enormously in their tolerance to alcohol. The 
periodic drinkers possess little will power and are started on a drink- 
ing bout by slight provocation ; they tend to become steady drinkers 
similar to those just described. Dipsomaniacs are periodic drinkers, 
but in reality insane. 

The attacks are sudden and irresistible. They may last a day 
or two, or weeks, and there may be complete loss of memory during 
the seizure. 

Treatment. — After an attack of ordinary drunkenness with loss 
of appetite, nausea, constipation, headache, restlessness, remorse, 
mental depression, and weakness, the patient may take a teaspoonful 
of aromatic spirits of ammonia (in which is placed a little red 
pepper), in cracked ice and water every hour. If there is much 
vomiting, a teaspoonful of syrup of ipecac, followed by several 
glasses of water, will serve to wash out the stomach and aid recov- 
ery. When the vomiting has stopped the patient should take three 
compound cathartic pills. 



CHRONIC ALCOHOLISM 649 

The treatment of chronic alcoholism should be done in accord- 
ance with a patient's desire — forcible detention and treatment will 
not accomplish much. It is better to care for the patient in a hos- 
pital or sanatorium and not in his home. Alcohol should be grad- 
ually withdrawn, giving two to four tablespoonfuls of whisky in 
milk the first day, only half of this amount the second, and none the 
third day. In the young and strong, alcohol may be stopped at 
once. 

The diet should consist of a glass of milk, buttermilk, egg nog, 
broth, cereal, gruel, or tea or coffee with considerable cream, every 
two hours. 

In the beginning free purging is essential. Four or five com- 
pound cathartic pills are to be taken at one dose. The older methods 
consisted in the use of proper diet, rest in bed, applications of 
water in various forms to the body, in baths, sprays, and packs, 
together with massage and exercise — all requiring several months. 
In this country Lambert's treatment is now chiefly in favor, in 
which by the use of free purging, by the production of sleep, the 
giving of his special mixture, and stimulation with strychnin, the 
craving is removed within a few days and the patient may be "cured" 
in a week or more. If the patient ever drinks again the craving 
will, however, return and he should be under a doctor's supervision 
for some months, making a weekly visit to his office; any special 
disorders produced by drink should be treated. Unless the sur- 
roundings are favorable to recovery, after the patient returns to his 
home, the cure will not be permanent. 



CHAPTER IX 
ACUTE AND CHRONIC BEIGHT'S DISEASE OE THE KIDNEYS 

BRIGHT S DISEASE OF THE KIDNEYS 

Blight's disease of the kidneys is acute or chronic, and its pres- 
ence can be definitely determined only by physical examination of 
the patient together with chemical and microscopical examination of 
the nrine. Acute Bright's disease coming on in persons previously 
well, may, however, present certain symptoms by which its existence 
may be suspected even by the layman. 

ACUTE BRIGHT'S DISEASE 
(Acute Inflammation of the Kidneys) 

Causes. — Acute Bright's disease is often the result of exposure 
to col:: and ~ ret Inflammation of the kidneys may be produced by 
swallowing turpentine, many of the cheap flavoring extracts in large 
amounts, carbolic acid, and Spanish flies; the external use of large 
quantities of turpentine, carbolic acid, or Spanish flies may also 
lead to acute inflammation of the kidneys. It occurs not infre- 
quently in pregnant women. 

The contagious germ diseases are very frequently the source of 
acute Bright's disease, which is then either a complication or a sequel. 
Thus scarlet fever is the most frequent cause, but measles, smallpox, 
chicken pox, yellow fever, typhoid fever, erysipelas, diphtheria, 
cholera, and malaria are also causative factors. Acute Bright's 
disease may be secondary to acute tonsillitis, blood poisoning, sur- 
gery of the kidneys, syphilis, tuberculosis, and severe burns and 
injuries. 

650 






BRIGHT'S DISEASE OF THE KIDNEYS 651 

Symptoms. — Acute Bright's disease may develop suddenly with 
pallor and puffiness of the face, owing to dropsy. The eyelids, 
ankles, legs, and lower part of the belly are apt to show signs of 
the dropsy most. There may be nausea, vomiting, pain, and lame- 
ness in the small part of the back, chills and fever, loss of appetite, 
and often constipation. In children convulsions sometimes appear. 
The urine is small in amount, perhaps not more than a cupful in 
twenty-four hours, instead of the normal daily excretion of three 
pints. Occasionally complete suppression of the urine occurs. It 
is high-colored, either smoky or of a porter-color, or sometimes a 
dark or even bright red, from the pressure of blood. 

Stupor and unconsciousness may supervene in severe cases. Re- 
covery usually occurs in favorable cases, within a few weeks, with 
gradually diminishing dropsy and increasing secretion of urine, or 
the disease may end in a chronic disorder of the kidneys. If acute 
Bright's disease is caused by, or complicated with, other diseases, 
the probable result becomes much more difficult to predict. 

Treatment. — The failure of the kidneys to perform their usual 
function of eliminating waste matter from the blood makes it neces- 
sary for the skin and bowels to do double duty. The patient should 
be kept very warm in bed, with flannel night clothes and blankets 
next to the body. 

If possible, the diet should consist wholly of milk and water, 
alternating a glass of each every hour during the day; when milk 
cannot be taken readily thin gruels made with milk may be used. 
Or a small amount of Apollinaris water, lime water, tea, or coffee 
can be added to milk to make it more palatable. Imperial drink, 
made by adding a teaspoonful of cream of tartar, the juice of half 
a lemon and sugar to a pint of boiling water, should be taken daily, 
in two doses (in place of two glasses of pure water), to increase 
the secretion of urine and aid the action of the bowels. Salt must 
not be given to patients at all as it favors dropsy. As the patient 
improves, bread and butter, green and juicy vegetables, and fruits 
may be permitted. 

The bowels should be kept loose from the outset by salts given 
in as little water as possible, and immediately followed by a glass 



652 ACUTE AND CHRONIC BRIGHT'S DISEASE 

of pure water. A teaspoonful may be given hourly until the bowels 
move. Epsom or Glauber's salts are efficient, but the compound 
jalap powder is the best purgative. Children, or those to whom 
these remedies are repugnant, may take the solution of citrate 
of magnesia, of which the dose is one-half to a whole bottle for 
adults. 

The skin may be stimulated by the patient's lying in a hot bath 
for twenty minutes each day, or, if this is not possible, by wrapping 
the patient in a blanket wrung out of hot water and covered by a 
dry blanket and then by a rubber or waterproof sheet, and he should 
be allowed to remain in it for an hour with a cold cloth to the head. 
If the patient takes the hot bath he should immediately be wrapped 
in warm blankets on leaving it, and should receive a hot drink of 
lemonade to stimulate sweating. 

Vomiting is allayed by swallowing cracked ice in Apollinaris 
water, single doses of bismuth subnitrate (one-quarter teaspoonful) 
once in three hours, and by heat applied externally over the stomach. 
Recovery is hastened by avoiding cold and damp, and persisting 
with a liquid diet for a considerable length of time. 

A course of iron is usually desirable after a few weeks have 
elapsed to improve the quality of the blood. The following is the 
dose: for adults, ten drops of the tincture of the chlorid of iron 
taken in water through a glass tube ; for children, five to ten drops 
of the syrup of the iodid of iron. In either case the medicine should 
be taken three times daily after meals. 

CHRONIC BRIGHT'S DISEASE 

This includes several forms of kidney disease. The symptoms 
are often very obscure, and the condition may not be discovered or 
suspected by the physician until an examination of the urine, blood 
pressure, or heart is made. It should therefore emphasize the im- 
portance of regular, yearly, complete, physical examinations of 
every individual. This advice is particularly important for persons 
who have reached middle age. 

Accidental discovery of Bright's disease during examination for 
life insurance is not rare. The disease mav exist for years without 



BRIGHT'S DISEASE OF THE KIDNEYS 653 

giving rise to sufficient trouble to cause the patient to seek the advice 
of a doctor. 

Causes. — Chronic Bright's disease often follows, and is the re- 
sult of fevers, malaria, infections, and acute inflammation of the 
kidneys. It is more common in adults, and is often hereditary. 
Overeating, more especially of meat, and overdrinking of alcohol, 
are sometimes causes. Gout and syphilis are common factors in 
its causation, also the strenuous life with "high living." The imme- 
diate cause of the more common form of chronic Bright's disease is 
at present unknown. 

It is not a disease of the kidneys alone, but the blood vessels 
become thickened and narrowed, and the heart is enlarged to force 
the blood through the partially choked blood vessels and the diseased 
kidneys. Ultimately the end comes through failure of the kidneys 
to function or, more often, through rupture of the blood vessels 
(apoplexy) or failure of the overworked heart, and resulting dropsy. 

Symptoms.' — The symptoms are most diverse and varied, and it 
is not possible to be sure of the existence of the disease without a 
careful physical examination, together with a complete analysis of 
the urine (collected for twenty-four hours), both made by a compe- 
tent physician. Patients may be afflicted with the disease for long 
periods without any symptoms, until some sudden complication calls 
attention to the underlying trouble. 

Symptoms suggesting chronic Bright's disease are among the fol- 
lowing: loss of strength and energy, rising several times at night 
to pass water, sleeplessness, furred tongue, indigestion, diarrhea 
and vomiting, frequent headache, shortness of breath, paleness, puf- 
finess of the eyelids, swelling of the feet in the morning, dropsy, 
failure of eyesight, nosebleed and, at times, apoplexy. As the disease 
comes on slowly, the patient usually has time to apply for medical 
aid, and attention is called to the foregoing symptoms (only a few 
of which are commonly present in one individual) merely to em- 
phasize the importance of attending to such in due season. 

Outlook. — While the outlook as to complete recovery is very 
discouraging, in many cases persons may live and be able to work 
for years in comparative comfort. When a physician pronounces 



654 ACUTE AND CHROXIC BRIGHTS DISEASE 

the verdict of chronic Bright's disease, it is not by any means equiva- 
lent to a death warrant, but the condition is often compatible with 
years (ten to fifteen or more) of usefulness and freedom from seri- 
ous suffering. 

Treatment. — Medicines will not cure Bright's disease, and in the 
earlier stages they are not desirable. The essentials of treatment 
include a quiet life free from care, worry, and excitement, with 
a moderate diet consisting chiefly of vegetables (except onions, rad- 
ishes, and dried peas and beans), bread, all cereals, and fats — as 
butter, cream, bacon, and salad oil. Fish, shellfish, eggs, and meat 
should be eaten sparingly. One of these may be taken once daily, 
but in very moderate amount. A pint of cream and six to eight 
glasses of water should be taken daily, or enough to cause the pas- 
sage of three pints to two quarts of urine in the twenty-four hours. 

The underclothing should be of wool the year round. A warm 
bath ought to be taken daily, with vigorous friction to excite the 
action of the skin, and it is important to always keep warm. When 
possible the patient should spend the winter in a warm, dry climate. 
Moderate daily walking is advisable. Biweekly sweats, taken with 
hot air cabinets sold by druggists, are often of great value, but their 
use should be endorsed by a physician. The bowels should be kept 
active by a small dose of mineral water or Epsom salts (in a glass 
of water) on arising. Tea or coffee allowable once a day. 

Medicines have their usefulness to relieve special conditions, but 
are only to be taken upon the advice of a physician, whose services 
should alwavs be secured when available. 



CHAPTER X 
GENITO-UKINARY DISEASES 

Gonorrhea in men and women. Syphilis. Prevention of gonorrhea and 
syphilis. Cystitis. Enlarged prostate. Bed-wetting in children. 

GONORRHEA 

Gonorrhea in Men 

Causes. — Gonorrhea is a contagious inflammation of the urethra 
accompanied by a white or yellowish discharge. It is caused by a spe- 
cific germ, the gonococcus, and is acquired through sexual intercourse 
with a person suffering from this disease. The disease is said to 
occur in from seventy-five to ninety per cent, of all males, and is 
more common in cities. Exceptionally the disease may be conveyed 
by objects soiled with the discharge, as basins, towels, and, in chil- 
dren, diapers, so that in institutions for infants it may be thus trans- 
ferred from one to the other, causing an epidemic. 

The mucous membrane of the lower part of the bowel and the 
eyes are also subject to the disease through contamination with the 
discharge. 

Symptoms. — The disease begins usually three to seven days after 
sexual intercourse, with symptoms of burning, smarting, stinging, 
tickling, itching, and then pain on urination, and a watery discharge 
from the passage, soon followed by a yellowish or white secretion. 
Frequent urination is also a common symptom. 

The disease, if uncomplicated and running a favorable course, may 
end in recovery within six weeks or earlier, with proper treatment. 
On the other hand, complications are exceedingly frequent, and the 
disorder often terminates in a chronic inflammation which may persist 
for years — even without the knowledge of the patient — and may 

655 



656 GEXITO-URIXARY DISEASES 

result in the infection of others after all visible signs have ceased to 
appear. 

Treatment. — If possible consult a physician at once. Rest is the 
most important requisite ; it is best taken in bed, otherwise the patient 
should keep as quiet as possible for several days. 

The diet should consist of large quantities of water or milk, or 
milk and Apollinaris or Vichy, with bread, cereals, potatoes, and vege- 
tables — absolutely avoiding alcohol in any form. Sexual intercourse 
is harmful at any stage in the disease and will communicate the infec- 
tion. Aperient salts should be taken to keep the bowels loose. The 
parts affected should be soaked in warm water three times daily 
to reduce inflammation and for cleanliness. All cloths, cotton, etc., 
which have become soiled with the discharge, should be burned, and 
the hands should be washed after contact with the discharge ; other- 
wise the contagion may be conveyed to the eyes — producing blind- 
ness. It is advisable for the patient to take one-half teaspoonful 
of baking soda in water three times daily between meals for the first 
four or five days, or better fifteen grains of potassium citrate and 
fifteen drops of sweet spirit of niter in the same way. After all 
swelling and pain have subsided, local treatment may be begun. 

Injections or irrigations with various medicated fluids constitute 
the best and most efficient measures of local treatment. In case 
a physician cannot be obtained the injection of argyrol twice a day, 
as advised under prevention, is the best local remedy. Xo greater 
mistake can be made than to resort to the advertising quack, the drug- 
gist's clerk, or the prescription furnished by an obliging friend. 
Skillful treatment, resulting in a complete radical cure, may save 
much suffering from avoidable complications and months or years of 
chronic trouble. 

At the same time the first medicines advised are to be stopped, 
and oleoresin of cubebs, five grains, or copaiba balsam, ten grains — 
or both together — are to be taken in capsules, three times daily after 
meals, for several weeks, unless they disturb the digestion too much. 
A suspensory bandage should be worn throughout the continuance 
of the disease. 

The approach of the cure of the disease is marked by a diminution 



GONORRHEA G57 

in the quantity and a change in the character of the discharge, which 
becomes thinner and less purulent and reduced to merely a drop in the 
passage in the early morning; but this may continue for a great 
while. 

Chronic discharges of this kind and the complications cannot be 
treated properly by the patient, but require skilled medical care. 
In this connection it may be said that most patients have an idea that 
the subsidence or disappearance of the discharge is an evidence of the 
cure of the disease. Experience shows that the disease may lapse 
into a latent or chronic form and remain quiescent, without visible 
symptoms, during a long period, but susceptible of being revived 
under the influence of alcoholic drinks or sexual intercourse. It is 
important that treatment should be continued until all disease germs 
are destroyed, which can only be determined by the examination of 
the secretions from the urethra, under the microscope. 

Complications. — The more common complications of gonorrhea 
are inflammation of the glands in the groin (bubo), acute inflamma- 
tion of the prostate gland and bladder, of the seminal vesicles, or of 
the testicles. The latter complication is a most common cause of 
sterility in men. 

Formerly it was thought that gonorrhea was a local inflammation 
confined to the urinary canal and neighboring parts, but advances in 
our knowledge have shown that the germs may be taken up into 
the general circulation and may affect any part of the body, such as 
the muscles, joints, heart, lungs, liver, spleen, kidneys, etc., with re- 
sults often serious and sometimes fatal to life.. 

One of the most common complications is gonorrheal arthritis, 
which may attack one or several joints and result in stiffness or com- 
plete loss of movement of the affected joint, with more or less de- 
formity and permanent disability. Another complication is gonor- 
rheal inflammation of the eye, from direct transference of the pus by 
the fingers or otherwise, and resulting in partial or complete blind- 
ness. 

Gonorrhea in Women 

Causes. — Gonorrhea in women is a much more frequent and ser- 
ious disease than was formerly supposed. The general impression 



G58 GENIT0-UR1NARY DISEASES 

among the laity is that gonorrhea in women is limited to the prosti- 
tute and vicious classes who indulge in licentious relations. Un- 
fortunately, this is not the case. 

There is perhaps more gonorrhea, in the aggregate, among virtuous 
and respectable wives than among professional prostitutes, and the 
explanation follows: A large proportion of men contract the dis- 
ease at or before the marrying age. The great majority are not 
cured, and the disease simply lapses into a latent form. Many of 
them marry, believing themselves cured, and ignorant of the fact that 
they are bearers of contagion. They transmit the disease to the 
women they marry, many of whom, from motives of modesty and an 
unwillingness to undergo an examination, do not consult a physician, 
and they remain ignorant of the existence of the disease until their 
health is seriously impaired. 

Symptoms. — In women, gonorrhea is not so acute and painful 
as in men, unless it involves the urethra. It usually begins with 
smarting and painful urination, with frequent desire to urinate and 
with a more or less abundant discharge from the front passage. 
• In the majority of cases the infection takes place in the deeper 
parts, that is, in the neck of the womb. In this location it may not 
at first give rise to painful symptoms, and the patient often attributes 
the increased discharge to an aggravation of leukorrhea from which 
she may have suffered. The special danger to women from gon- 
orrhea is that the inflammation is apt to be aggravated during the 
menstrual period and the germs of the disease ascend to the cavity 
of the womb, the tubes, and ovaries, and invade the peritoneal cover- 
ing, and cause peritonitis. Pregnancy and childbirth afford favor- 
able opportunities for the upward ascension of the germs to the peri- 
toneal cavity. 

The changes caused by gonorrheal inflammation in the maternal 
organs are the most common cause of sterility in women. It is esti- 
mated that about fifty per cent, of all sterility in women proceeds 
from this cause. In addition to its effects, upon the child-bearing 
function, the danger to the health of such women is always serious. 
In the large proportion of cases they are made permanent invalids, 
no longer able to walk freely, but compelled to pass their lives in a 



GONORRHEA 659 

reclining position until worn out by suffering, which can only be 
relieved by the surgical removal of their maternal organs. It is 
estimated that from fifty to sixty per cent, of all operations per- 
formed on the maternal organs of women are due to disease caused by 
gonorrheal inflammation. 

Treatment. — Rest in bed, the use of injections of hot water medi- 
cated with various drugs, by means of a fountain syringe in the 
front passage three times daily, and the same internal remedies recom- 
mended for men, with hot sitz baths, will usually relieve the dis- 
tress. 

In view of the serious character of this affection in women and its 
unfortunate results when not properly treated, it is important that 
they should have the benefit of prompt and skillful treatment by a 
physician; otherwise the health and life of the patient may be ser- 
iously compromised. 

The social danger of gonorrhea introduced after marriage is not 
limited to the health of the woman. When a woman thus infected 
bears a child the contagion of the disease may be conveyed to the 
eyes of the child in the process of birth. Gonorrheal pus is the most 
virulent of all poisons. A single drop of the pus transferred to the 
eye may destroy this organ in from twenty-four to forty-eight hours. 
It is estimated that from seventy-five to eighty per cent, of all 
babies blinded at birth have suffered from this cause, while from 
twenty to thirty per cent, of blindness from all causes is due to gon- 
orrhea. 

While the horrors of this disease in the new-born have been miti- 
gated by the Crede method (dropping of two per cent, nitrate of 
silver solution in the eye immediately after birth), gonorrhea still 
remains one of the most common factors in the causation of blindness, 
when there is neglect to use this method. Another social danger is 
caused by the pus being conveyed to the congenital parts of female 
children, either at birth or later by some object upon which it has 
been accidentally deposited, such as clothes, sponges, diapers, etc. 

The disease occurring in children is exceedingly difficult of cure 
and is often followed by impairment in the development of their ma- 
ternal organs. Much of the ill health of young girls from disordered 



660 GEXITO-I7PJXABY DISEASES 

menstrua t ion and other uterine diseases may be traced to this cause. 
Another serious infection in babies and young children is gon- 
orrheal inflammation of the joints, with more or less permanent crip- 
pling. 

SYPHILIS 

(The Pox — Lues) 

Syphilis is a contagious germ disease affecting the entire system. 
While commonly acquired through sexual intercourse with a person 
affected with the disorder, it may be communicated from a mother 
to her infant while in the womb before birth'. Syphilis is thus ac- 
quired by the child before birth from the mother and not from the 
father — except indirectly as he infected the mother. 

It is authoritatively stated that 13 per cent, of persons acquire 
syphilis and 1,650,000 are affected annually in this country (Ed- 
wards). This is borne out by the testing of large numbers of persons 
promiscuously in which the Wassermann test in some regions has 
shown one positive reaction in eight individuals. Syphilis and tuber- 
culosis are the two great destroyers of health and happiness, but syph- 
ilis is the more common. 

Symptoms. — Acquired syphilis may be divided into three stages : 
the primary, secondary, and the tertiary. 

The first stage is characterized by the appearance of a pimple 
or sore on the surface of the sexual organ, not usually earlier than 
two, nor later than five to seven weeks, after sexual intercourse. 
The appearance of this first sore is subject to such variations that 
it is not always possible for even the most skillful physician to de- 
termine the presence of syphilis, by physical examination, until the 
symptoms characteristic of the second stage develop. A raw sore 
with hard deposit beneath, as of a coin under the skin, follows the 
pimple on the surface. It may be so slight as to pass unnoticed, or 
become a large ulcer, and may last from a few weeks to several 
months. There are several other kinds of sores which have no con- 
nection with syphilis and yet may resemble the syphilitic sore so 
closely that it becomes impossible to distinguish between them. So 
that formerly the rule was to wait until the later symptoms devel- 



SYPHILIS 661 

oped before a positive diagnosis was made; then it was too late to 
cure the disease at once. Xow a specimen from the sore should al- 
ways be examined microscopically for the presence of the germ of 
syphilis. If found, the patient may be cured at once and for all time 
by immediate treatment with salvarsan and mercury. Along with 
this sore, lumps usually occur in both groins, due to enlarged glands. 

The second stage appears in six to seven weeks after the initial 
sore, and is characterized by the occurrence of a copper-colored 
rash over the body, but not often on the face, which resembles measles 
considerably. Sometimes a pimply or scaly eruption is seen following 
this, or in place of the red rash. At about, or preceding, this period, 
other symptoms may develop, as fever, headache, nausea, loss of appe- 
tite, and sleeplessness ; but these may not be prominent. Moist patches 
may appear on the skin, in the armpits, between the toes, and about 
the rectum ; or warty outgrowths in the latter region. There is sore 
throat, with frequently grayish patches on the inside of the cheeks, 
lips, and tongue. The hair falls out in patches, or less often is all 
lost. Inflammation of the eye is sometimes a symptom. These symp- 
toms do not always occur at the same time, and some may be absent 
or less noticeable than others. 

The third stage comes on after months or years, or in those sub- 
jected to treatment it may not occur at all. This stage is character- 
ized by sores and ulcerations on the skin and deeper tissues, and the 
occurrence of disease of different organs of the body, including the 
muscles, bones, nervous system, and blood vessels; every internal 
organ is susceptible to syphilitic change. 

A great many affections of the internal organs — the heart, lungs, 
kidneys, brain, and cord, — which were formerly attributed to other 
causes, are now recognized to be the result of syphilis. The central 
nervous system is peculiarly susceptible to the action of syphilis, 
and, when affected, may show it by paralysis and disabling and dis- 
figuring disorders. Such nervous disorders often occur years after 
a cure of syphilis has apparently resulted. 

Thus locomotor ataxia is syphilis of the spinal cord, and paresis 
or "softening of the brain" is syphilis of the brain. Formerly it 
was thought that these diseases might result from other causes than 



662 GENITO-URINARY DISEASES 

syphilis, or that they were the result of the poison of syphilis after 
the germ had disappeared. Now we know that syphilis in any form 
is not cured while any of the germs are alive in the body, and that 
locomotor ataxia and paresis are the direct results of the action of the 
syphilitic germ on the nervous system. 

Outlook. — Children born with syphilis of syphilitic parents show 
evidence of the disease at birth or usually within one or two months. 
They present a gaunt wasted appearance, suffer continually from 
snuffles or nasal catarrh, have sores and cracks about the lips, loss of 
hair, and troublesome skin eruptions. The syphilitic child has been 
described as "a little old man with a cold in his head." 

The internal organs are almost invariably diseased and the infant 
mortality is about 75 per cent. Of those that survive birth 95 per 
cent, of syphilitic children die if untreated, but only 10 per cent, 
if properly treated (Etienne) ; while only 3 per cent, perish if the 
parents are treated during pregnancy (Fournier). But those who 
live to grow up may be puny and poorly developed and are prone to 
be delicate. 

Causes. — It is to be noted that syphilis is not necessarily a vene- 
real disease that is acquired through sexual relations. It may be 
communicated by kissing, by accidental contact with a sore on the 
patient's body, or by the use of pipes, drinking or eating utensils, or 
by contact with any object soiled with the virus of the disease. The 
secretions as nasal mucus, saliva, sweat, urine, and excrement of 
patients are not contagious unless they contain some blood in which 
the germs live. 

Any mucous membrane or abraded part of the skin may become 
inoculated with the virus of syphilis, followed by a sore similar to 
that described as appearing on the private parts, and later by the de- 
velopment of general symptoms. The contagiousness of the dis- 
ease is supposed to last during the first three years of its existence, 
but there are many authentic cases of contagion communicated by 
persons in the fourth and fifth year of the disease. 

Diagnosis. — The positive determination of the existence of syphi- 
lis at the earliest moment is of the utmost importance in order to set 
doubt at rest, and so that treatment may be begun. It has hereto- 



SYPHILIS 663 

fore been necessary to wait until the appearance of all of the charac- 
teristic symptoms — as the eruption, sore throat, enlargement of the 
glands, falling of the hair, etc., — before it was considered safe to 
be positive. In later cases when the symptoms were doubtful one 
had to experiment with treatment in order to diagnose a case. The 
recently discovered Wassermann reaction is reliable after six weeks 
from the time of beginning syphilitic infection and at any later date, 
as long as syphilitic germs remain in the body. No test is more valu- 
able (except microscopic examination of a specimen from the first 
sore, see above), because it has been impossible otherwise to diagnose 
a large proportion of syphilitic patients. 

Many persons are unaware of having the disease when it is pres- 
ent, and some have acquired it other than by the usual method. The 
Wassermann test is probably accurate in 80 to 90 per cent, of cases 
of syphilis with manifestations (Osier). Treatment will cause the 
test to become negative but if the patient is not permanently cured by 
the destruction of the syphilitic parasites, the test will again prove 
positive. 

Treatment.- — Treatment should be begun as soon as the diagnosis 
is made, and must be continued continuously or intermittently for 
two or three years. If treatment is instituted before the secondary 
symptoms it may prevent their appearance so the patient may re- 
main in doubt whether he has the disease or not — unless there has 
been a positive Wassermann test or microscopic examination of a 
specimen from the sore. 

The most skilled specialist cannot always distinguish the disease 
before the eruption appears, because other sores on the sexual organs 
may closely simulate syphilis. 

The treatment has hitherto been conducted first with mercury 
and then with a mixture of mercury and iodid of potash. Very 
considerable knowledge and skill are required in adopting these 
to the individual needs and the peculiarities of the patients, so 
that it would be an impossibility to satisfactorily describe their use 
to a layman. Erlich's great discovery of salvarsan ("606") was 
thought to supply a remedy which would cure syphilis for all time by 
the use of one injection. This has been found not to be true except 



66-i GENITO-UBIXARY DISEASES 

in unusual cases, but it often is true if the remedy is given soon 
after the first appearance of the primary sore. Nevertheless, the 
remedy kills immensely larger numbers of the syphilis parasite at 
one dose than does mercury, which takes weeks or months of daily 
use to accomplish what is done by salvarsan in one injection. Three 
to five doses of salvarsan are commonly injected into a vein, one week 
apart, as soon as a diagnosis is made, and after this mercury is given 
by injection or rubbing on the skin and, following this, by the mouth 
for a period of two or more years. 

The earliest date at which marriage is permissible, following 
thorough treatment, is two full years after the beginning of the dis- 
ease, and at least one year after all symptoms haA^e disappeared 
(Osier) (See below). If these conditions have been complied with, 
there is little danger of men communicating the disease to their 
wives and by that manner to their offspring. Abstinence from alco- 
hol, tobacco, dissipation, and special care of the teeth, are necessary 
during treatment. 

Outlook.' — The majority of syphilitics recover wholly under treat- 
ment and neither have a return of the disease nor do they communi- 
cate it to their wives or children. There are, however, cases on rec- 
ord, in which a man has communicated the disease five or six years 
after apparent recovery, and one can never promise that there will 
never be a return of the disease. By taking the Wassermann test 
at three or six month intervals one would now be warned of the re- 
turn of the disease. 

Without proper treatment, or without treatment for the proper 
time, recurrence of the disease is frequent, with the presence of 
destructive and serious conditions characteristic of the third stage of 
syphilis. 

By return of the disease is meant a return of symptoms of syph- 
ilis. If all the syphilitic germs have been killed the disease can 
never come back. But very often the patient is apparently perfectly 
recovered and cannot transmit the disease to others (absence of germs 
in his blood), and his blood test (Wassermann) is negative. But 
the germs may live deeply buried in the tissues and, after a period 
of five, ten, fifteen, or even twenty years, such sequelae as paresis 



SYPHILIS 665 

or locomotor ataxia (or a host of other syphilitic conditions) may 
develop. While syphilis is not so fatal to life as tuberculosis, it is 
the cause of more unhappiness and suffering. 

Abortion is one of its most common manifestations in syphilitic 
women. Abortion or premature birth occurred in 40 per cent, of 330 
syphilitic pregnancies, according to Edwards. Syphilis is wholly 
preventable while, at present, tuberculosis is not. It is not probable 
that syphilis is ever transmitted to the third generation, but deformi- 
ties, general debility, small and poor teeth, thin and scanty growth 
of hair, nervous disorders and a generally miserable physique are 
seen in children whose parents were the victims of inherited syphilis. 

Syphilis Not Truly Inherited. — In married life syphilis may be 
communicated to the wife directly from a primary sore on the genitals 
of the husband during sexual intercourse, but contamination of the 
wife more often occurs from the later manifestations of the dis- 
ease in the husband, as from secretions of open sores on the surface 
of the body or from the mouth, when moist patches exist there. It 
has commonly been taught that a child truly inherits syphilis by 
acquiring the parasites through the semen of the father at the time 
of conception. This is now denied by the highest authorities (Osier) 
who affirm that the disease is always acquired by direct infection of 
the child in the mother's womb, from the mother herself, who in 
her turn has been infected by the father or by some other person or 
source. The theory of direct inheritance from the father was based 
upon the fact that syphilitic babies were born from apparently 
healthy mothers. The use of the Wassermann test shows that such 
mothers have syphilis. If, however, the mother acquire syphilis late 
in pregnancy the child may escape unharmed. A child born ap- 
parently healthy of a syphilitic mother may be nursed without 
danger to the child by the mother, as it has acquired immunity. But 
if a syphilitic child is born of an apparently healthy mother (but 
necessarily a syphilitic) there is no danger of the child infecting the 
mother although it would infect a healthy nurse who merely handled 
it or suckled it. 

The chief social danger of syphilis arises from its introduction into 
married life and its possible radiations by accidental infection, 



666 GENITO-UBINABY DISEASES 

through, society. Probably one in every five cases of syphilis in 
women is communicated to them in the marriage relation. There are 
so many sources and modes of contagion that it is spread from one to 
another innocently in the ordinary relations of social life. From 
husband to wife, from wife to child, from child to nurse and other 
members of the family, so that small epidemics may arise. 

As has been seen, a large proportion of the progeny of syphilitics 
die during pregnancy, or soon after birth, and those who survive are 
blighted physically and mentally and are unfit for the battle of life. 
Syphilis has come to be recognized as one of the most powerful fac- 
tors in the depopulation and degeneration of the race. 

The United States Government has issued a bulletin 1 in which 
the standard of cure is stated to be "one year without treatment, with- 
out any suspicious signs, with several negative Wassermann reactions 
and no positive ones, and with a negative provocative Wassermann 
reaction (i. e., following a dose of salvarsan in two to fourteen days) 
and negative luetin test at the end of the year." Luetin is an emul- 
sion of the dead syphilitic germs, one drop of which is mixed with a 
drop of sterile salt solution and injected under the skin. It gives 
rise to a pimple or pustule within one or two days, or three or four 
weeks, in latent, late, and nervous forms of syphilis, but produces no 
such effect in the absence of syphilis. 

Prevention of Gonorrhea and Syphilis 

While at first thought it may be questioned whether it is rightly 
advisable to protect persons from nature's punishment, which so often 
follows immoral sexual relations, still when we reflect that the exis- 
tence of sexual disease often endangers absolutely innocent indi- 
viduals it must be conceded that these must be protected whenever 
possible. 

We will repeat some of the results of sexual disease to emphasize 
its importance. Accidental infection with syphilis is not a rare occur- 
rence by means of drinking cups, pipes, table implements, napkins 
and towels, and by instruments used by barbers, manicures, and 

1 Treatment of Syphilis, U. S. Public Health Service, Jan., 1915. 



SYPHILIS 607 

even careless dentists and doctors. By marriage the pure and healthy 
wife may either become a chronic invalid, a subject for serious sur- 
gery, through acquiring gonorrhea from a husband, or even worse, 
through the same means, may inflict total and incurable blindness on 
her newborn child, or give birth to progeny cursed with the doom 
of congenital syphilis acquired from a syphilitic husband and father. 

It is now the custom in the United States Navy to give preventive 
treatment, immediately upon return to their vessels, to men on shore 
leave who have been exposed, through sexual relations, to gonorrhea 
and syphilis. The result is that these hitherto most common mala- 
dies have been almost abolished on shipboard, where the method is 
thoroughly carried out. 

One of the questions most frequently asked by those with gon- 
orrhea is, When can I safely marry ? The germs of gonorrhea, as has 
been stated, may lie dormant for years in the urinary passage, or 
glands, or ducts connected with it, only to be stimulated into renewed 
activity so as to produce a fresh, acute attack (which may be com- 
municated to a woman) through agencies which irritate the part — as 
by alcoholic or sexual excess. 

The man who has had gonorrhea and wishes to marry should pre- 
sent himself to an expert, who will examine any discharge with a 
microscope, or if there are apparently no signs of trouble, the doctor 
will pass a sound, massage the prostate gland through the rectum, 
and get the patient to pass water which may contain the germs. 
Again, he will require the patient to drink two bottles of beer, to see 
if the irritation occasioned by this will bring to light any germs in 
the urine. The newly discovered blood test (complement fixation 
test) may solve the question without any other examination, and is 
the simplest means for the patient, although requiring a skillful lab- 
oratory man for its performance. The results of the test are very sat- 
isfactory, providing the gonorrhea has not been acquired within the 
previous few months. 

Such are the methods which should be employed in the case of any 
man who has had gonorrhea and wishes to marry — even if he ap- 
pears perfectly well, has no shreds in his urine, and years have 
elapsed since apparent cure of his trouble. 



668 GENITO-UEINAEY DISEASES 

In respect to syphilis the now widely known Wassermann test 
should always be employed on any man who has had gonorrhea before 
marriage. There are many eases of syphilis acquired during a se- 
vere attack of gonorrhea which passed unnoticed at the time. 

To prevent the occurrence of sexual disease, immediately after ex- 
posure, the following methods have been adopted in the army and 
navy : — A freshly made twenty per cent, solution of argyrol is drop- 
ped into the urinary passage of the male, and the end of the passage 
pinched for five minutes to prevent the escape of the fluid. One may 
fill an ordinary medicine dropper full, and use it once and, if done 
immediately or even within twelve bourse of exposure, the argyrol 
will usually avert the disease. Argyrol is used for many purposes, 
and no suspicion is attached to the buying of it. Fifteen grains 
should be bought, and so that it may last, it must be dispensed in a 
glass bottle ; the entire contents should be dissolved in one teaspoon- 
ful of lukewarm water when it is to be used. 

Following the injection of argyrol, the subject should wash his 
penis thoroughly in soap and water and then apply to it the following 
ointment : calomel. 1 drachm ; and lanolin, 2 drachms. This will, 
in all probability, prevent the occurrence of syphilis if applied 
within twelve hours after exposure. Xot the least discomfort is pro- 
duced by either argyrol or the calomel ointment. Before dropping 
in the argyrol solution the subject should pass urine, so as to avoid 
doing so for some hours after using the argyrol. 

INFLAMMATION OF THE BLADDER 

(Cystitis) 

Inflammation of the bladder commonly causes frequent and pain- 
ful urination. The urine is more or less cloudy and tinged with 
blood, and deposits a sediment on standing. 

Causes. — The immediate cause of inflammation of the bladder is 
the presence of germs, but the bladder is very resistent to germs un- 
less it is first irritated by some mechanical or chemical means or by 
extension of disease of neighboring organs. The germs enter from 
the blood into the urine in the kidnevs, or by means of unclean 



INFLAMMATION OF THE BLADDER 669 

instruments, as catheters introduced into the bladder, or by direct ex- 
tension from the disease of neighboring parts, as in gonorrhea of the 
sexual organs, or tuberculosis of the kidneys or sexual organs, or from 
various inflammations of the sexual organs of women, as in childbed 
infections. One of the commonest forms of cystitis is that caused by 
the germs inhabiting the bowels (colon bacilli) and these enter the 
blood and find their way into the urinary tract from the kidneys, 
especially in persons habitually constipated. 

We will mention the causes of irritation and congestion of the 
bladder which weaken it so that germs can flourish and produce 
cystitis. 

Mechanical Irritation. — This is seen in stone in the bladder, also 
following external blows and injuries, and also in retention of the 
urine from failure to empty the bladder — owing to spasm from pain 
or operation, and lastly from tumors. 

Thus in men of middle age, or past middle age, enlargement of the 
prostate gland (not present in females) surrounding the outlet of 
the bladder, produces retention. While the bladder is emptied 
regularly, some quantity of urine still remains, decomposes and 
irritates the bladder. The symptoms of such a condition are fre- 
quent passage of urine, the patient arising often at night, and, in 
advanced cases, inability to pass water at all without the introduc- 
tion of a catheter. 

The diagnosis of enlarged prostate is made by the finger in the 
lower bowel (rectum) or by means of an instrument passed into the 
bladder through which one can see by the aid of an electric light. 

In young (or older) men, narrowing of the urinary passage 
(urethra), a sequel to gonorrhea called stricture, may cause retention 
of urine and cystitis. 

In certain spinal diseases and injuries the bladder becomes para- 
lyzed and cannot empty itself, and in consequence cystitis ensues from 
retention of urine. 

Chemical Irritation. — Chemical irritation of the bladder arises 
from an over-acid or over-alkaline urine, from the swallowing of 
irritants — as certain waters and foods in some persons, large amounts 
of alcohol, and such drugs as turpentine or cantharides. The latter 



GEXITO-UPJXAEY DISEASES 

may even cause cystitis when used in excess externally. Exposure 
to cold — as sitting on damp, cold ground — may lead to congestion, 
and thus to inflammation of the bladder. 

Forms. — Cystitis may be either acute or chronic The acute 
form comes on suddenly and disappears after some days or weeks 
or merges into the chronic form. It often happens that a severe 
acute attack appears in a person having a low grade chronic cystitis 
which has caused little inconvenience.. 

Symptoms. — The combination of frequent and painful urination, 
with the appearance of blood or white cloudiness and sediment in the 
'ziir, are t""::-l;^ ;: :Ee t:::-"t^:t :: IrdammaTicrii -:f :Ee Kaiier 
(although they are as characteristic of kidney inflammation and stone. 
tumor, and many other conditions — See below). The trouble i c ag- 
gravated by standing, jolting, or other active exercise. The pain may 
be felt either at the beginning or end of urination. There is also 
generally a feeling of weight and heaviness low down in the belly, or 
about the lower part of the bowel. 

Blood is not frequently present, but the urine is not clear if there 
is much inflammation, and deposits a white, and often slimy, sediment 
on standing. If much blood escapes in the urine, one must suspect 
stone, tumor, tuberculosis, etc., and consult an expert in genito-urin- 
ary diseases. In chronic inflanmiation of the bladder the urine some- 
times has a foul odor and smells of ammonia. 

Diagnosis. — Certain points should be strongly emphasized in 
this connection. Formerly it was taught that microscopical examina- 
tion of the sediment of the urine would indicate from which parts of 
the urinary tract cells found in the urine were derived, and. in that 
one could tell precisely what portion of the tract was diseased. 
This is not the case, and it is a most common mistake of physicians 
to diagnose eases - stitis in which the symptoms already described 
occur. 

The same symptoms observed in inflammation of the bladder 
are also seen in inflammation, tuberculosis, stone, and tumor of the 
kidneys ; and in all cases in which apparent cystitis becomes chronic or 
in which blood appears in the urine, the newer methods of diagnosis 
must be employed. Even in cystitis these methods are equally de- 



INFLAMMATION OF THE BLADDER G71 

manded to exclude the presence of stone, tuberculosis, tumor, and 
rare conditions situated in the bladder itself. Indeed, among sur- 
geons, the presentation of a patient supposed to have a chronic 
cystitis immediately arouses the suspicion of some disease of the 
kidney or other condition in the bladder, to account for the appar- 
ent cystitis. Chronic cystitis is a symptom rather than a disease. 

The newer methods enable us to look into the bladder by means 
of electric illumination, to determine its appearance and contents, 
to draw urine directly from each kidney, and to determine the size 
and shape of the cavities in the kidneys and the presence of stone 
(by means of the x-ray) in any part of the urinary tract. 

Treatment. — The treatment of acute cystitis consists in rest in 
bed — -preferably on the back, with the legs drawn up. The diet 
should be chiefly fluid (one glass hourly), as milk, pure water, flax- 
seed tea, or mineral waters. Potassium citrate (fifteen grains) and 
sweet spirits of niter (fifteen drops) may be given in water to advan- 
tage three times daily. Hot full baths or sitz baths two or three times 
a day, and in women, hot vaginal douches (that is, injections into 
the front passage), with hot poultices or the hot water bag over the 
lower part of the abdomen, will" serve to relieve the suffering. If, how- 
ever, the pain and frequency attending urination is considerable, noth- 
ing is so efficient as a suppository containing one-quarter grain each of 
morphin sulphate x and belladonna extract, which should be intro- 
duced into the bowel and repeated once in three hours if neces- 
sary. This treatment should be employed only on the advice of a 
physician. 

In chronic cystitis, urotropin in ten grain doses in a whole glass 
of water, and taken four times daily, often affords great relief, but 
these cases demand careful study by a physician, to determine their 
cause, and often that local treatment may be given. Urotropin, in 
the above doses, sometimes upsets the stomach and causes increased 
irritability of the bladder, in which case the use of the drug must be 
stopped. 

Avoidance of all sources of irritation is also essential in these 

1 Morphin is a powerful drug and can only be obtained with a doctor's 
prescription. 



672 GEXITO-URIXARY DISEASES 

cases, as sexual excitement, and the use of alcohol and spices. The 
diet should consist chiefly of cereals and vegetables, with an abund- 
ance of milk and water — ten or twelve glasses daily. In acute cystitis, 
the bowels should be kept loose by means of hot rectal injections. 

From what has already been said it will be seen that no disease 
needs more careful study by an expert, than so-called or apparent 
inflammation of the bladder, more especially when it tends to become 
chronic. 

RETENTION, STOPPAGE, OR SUPPRESSION OF URINE 

Retention refers to that condition, in which the urine has been 
accumulating in the bladder for a considerable time — over twelve 
hours — and cannot be passed. It may follow an obstruction from 
disease, particularly an enlarged prostate gland (See above), to 
which is added temporary swelling and nervous contraction of some 
part of the urinary passage ; or it may be due to spasm and closure of 
the outlet from nervous irritation, as in cases of injuries and surgical 
operations in the vicinity of the sexual organs, the rectum, or in other 
parts of the body. Overdistention of the bladder from failure to 
pass water for a long time may lead to a condition where urination 
becomes an impossibility. 

Various general diseases, as severe fevers, and conditions of un- 
consciousness, and other disorders of the nervous system, are fre- 
quently accompanied by retention of urine. In retention of urine, 
there is often an escape of a little urine from time to time, and not 
necessarily entire absence of outflow. 

Treatment. — Retention of urine is a serious condition. If not re- 
lieved it may end in death from poisoning, or from rupture of the 
bladder. Therefore surgical assistance is demanded, as soon as it 
can be obtained. Failing this, one should begin with the simpler 
methods. 

A hot sitz bath, or, if the patient cannot move, hot applications — 
as a hot poultice or hot cloths applied over the lower part of the 
belly — may afford relief. Injections of hot water into the bowel are 
often still more efficient. A single full dose of opium in some form 
— as ten drops of laudanum or three teaspoons of paregoric, or one- 



INVOLUNTARY PASSAGE OF URINE 673 

quarter grain of morphin ! — will frequently allow of a free passage 
of urine. The introduction of a suppository into the bowel, contain- 
ing one-quarter grain each of morphin sulphate, 1 and belladonna 
extract, is often preferable to giving the drug by the mouth. 

These measures proving of no avail, the next endeavor should be 
to pass a catheter. If a soft rubber or elastic catheter is used with 
reasonable care, little damage can be done even by a novice. The 
catheter should be boiled in water for ten minutes, and after wash- 
ing his hands thoroughly the attendant should anoint the catheter 
with sweet oil (which has been boiled), or clean vaselin, and proceed 
to introduce the catheter slowly into the urinary passage until the 
urine begins to flow out through the instrument. 

A medium-sized catheter is most generally suitable — a number 
16 of the French scale or a number 8% of the English scale. 

INVOLUNTARY PASSAGE OF URINE— BED-WETTING IN CHILDREN 

(Incontinence of Urine — Enuresis) 

Causes. — This refers to an escape of urine from the bladder, un- 
controlled by the will. It naturally occurs in infants under thirty 
months, or thereabouts, and in the very old, and in connection with 
various diseases. It may be due to diseases of the brain, as in idiocy 
or insanity, apoplexy, or unconscious states. Injuries or disorders 
of the spinal cord — the latter controlling the action of the bladder 
(subject to the brain) — also cause incontinence. 

Local disorders of the urinary organs are more frequent causes of 
the trouble, as inflammation of any part of the urinary tract or private 
parts, diabetes, Bright's disease of the kidneys, stone in the bladder, 
tumors, and malformations. The involuntary passage of urine may 
arise from irritability of bladder — the most frequent cause — or from 
weakness of the muscles which restrain the escape of urine, or from 
obstruction to flow of urine from the bladder with overflow, when it 
becomes distended. 

It is a very common disorder of children and young persons, and 
in some cases no cause can be found ; but in many instances it is due 

1 Opium in any of its forms is a powerful drug and can only be obtained 
with a physician's prescription. 



674 GEXITO-ITRIXABY DISEASES 

to masturbation ; to a narrow foreskin and small aperture at the exit 
of the urinary passage ; to anemia ; to constipation ; to worms in the 
bowels or disease of the lower end of the intestines, such as fissure or 
eczema ; to digestive disorders ; to retaining the urine for too long a 
time ; to fright ; to dream impressions | dreaming of the act of urina- 
tion) ; and to great weakness brought on by fever or other diseases. 

In old men it is often due to an enlargement of a gland at the neck 
of the bladder (the prostate gland), which prevents the bladder from 
closing properly. A concentrated and irritating urine, from exces- 
sive acidity or alkalinity, may induce incontinence. 

Children may recover from it as they approach adult life, but 
they should not be punished, as it is a disease and not a fault. Ex- 
ception should be made in case children wet their clothing during 
play, through failure to take the time and trouble to pass water 
naturally. It is more common among children at night, leading 
to wetting of the bed. but may occur in the day, and often im- 
proves in the spring and summer, only to return with the cold 
weather. Children who sleep very soundly are more apt to be sub- 
ject to this disorder. 

Treatment. — In the case of a disorder depending upon one of so 
many conditions it will be realized that it would be folly for the 
layman to attempt to treat it. Children who are weak need building 
up in every possible way — as by an outdoor life, cold sponging daily, 
etc. 

If, in boys, there is a long foreskin, or tight foreskin, hindering 
the escape of urine and natural secretions of this part, circumcision 
may be performed to advantage by the surgeon, even in the infant a 
few weeks old. A somewhat corresponding condition in girls occa- 
sionally causes bed-wetting and other troubles. It can be discovered 
by a physician. 

Children who wet their beds, or clothes, should not drink liquid 
after five o'clock in the afternoon, and should be taken up at ten p. m. 
to pass water. The bed covering must be light, and children should 
be prevented from lying on their backs while asleep by wearing a 
towel knotted in the small part of the back. Elevation of the 
foot of the bed a few inches is recommended, as having a corrective 






INVOLUNTARY PASSAGE OF URINE 675 

influence by taking pressure of the urine from the outlet of the blad- 
der. Masturbation, if present, must be corrected. 

It is a very difficult disorder to treat, and one must not be over- 
critical of a physician for failure to remedy the evil, every attempt 
having been made to discover and remove the cause; even when cure 
seems assured, the disorder may recur. 

Belladonna is the most successful drug, but can only be used safely 
and effectively in accordance with a doctor's directions. 



CHAPTEE XI 

SEXUAL HYGIENE 

Every individual should understand the proper functions of the 
sexual organs and how to care for them, as well as those of any other 
part of the body, providing that the instruction be given by the proper 
person and at the proper time and place. Such information should be 
imparted to children by parents, guardians, teachers, or physicians 
at an early age, and if this is neglected through ignorance, false 
modesty, or erroneous ideas of the nature and purposes of the sexual 
function, it will surely be supplied in a way later by ignorant com- 
panions or evil-minded persons- — with correspondingly bad results. 

Is it not the most surprising fact that while the influence of sex 
on the lives of human beings is at times the most powerful in the 
world, still all reference to it has been omitted in the education of 
youth until recent years? There is no other responsibility in the 
whole range of parental duties which is so commonly shirked, and 
with such deplorable consequences. When the subject is shorn 
of the morbid and seductive mystery, with which custom has foolishly 
surrounded it in the past, and when considered in the same spirit with 
which we study the hygiene of digestion and other normal functions, 
it will be found possible to give instructions about the sexual func- 
tions in a natural way and without exciting unhealthy and morbid 
curiosity. 

A word in the beginning as to the harm produced by the abuse of 
the sexual function. The injury, while purposely magnified by 
quacks for reason of gain, is notwithstanding very real. The vol- 
untary exercise of the sexual functions — unlike that of any other 
important functions or organs — is not necessary to health. On the 
contrary, abstinence is conducive to health, both mental and physi- 

676 



SEXUAL HYGIENE 677 

cal, before maturity is reached. Even after maturity, unless mar- 
riage occurs or by improper living sexual desires are unnaturally 
stimulated, it is quite possible to maintain perfect health through 
life without exercising the sexual functions at all. Frequent or pro- 
longed excitement of the sexual organs causes local disease of these 
organs and overfatigue and failure of the nervous system which con- 
trols not only these organs, but every organ in the body. In other 
words, nervous breakdown or prostration follows. 

Local disorder of the sexual organs is caused by congestion and 
inflammation which produce impairment of function of the sexual 
organs, and often pain and distress, and frequency in urination. 

Excitement of the sexual organs in youth is particularly harmful 
because the nervous system is then more susceptible to damage and 
because there is no limit to the amount of sexual indulgence when 
self-abuse is practiced. Masturbation may be seen as early as one 
year of age and in both sexes. Sometimes the sexual organs are 
not rubbed with the hands, clothing, or against the bed, but the child 
rubs the thighs together or sits on the floor and crosses the thighs 
tightly and rocks to and fro. These actions may not be understood 
and be regarded as mere tricks. 

The child should be watched while in bed awake — that is, before 
sleeping and after waking. Self-abuse may be suspected in children 
who sleep badly, and are thin, nervous, and haggard looking. Boys 
who practice self-abuse are sallow, shy, absent-minded, depressed, and 
have a generally a hang-dog" appearance ; they are apt to stay by 
themselves and cease playing with their fellows. It is unncessary 
to further particularize, other than to state that abuse of the sexual 
organs in the young is usually owing to the almost criminal neglect 
or ignorance of the child's parents. 

Infants may be punished ; older children rewarded for good con- 
duct. We should try not to alarm the patient but, by kindly instruc- 
tion and judicious oversight in the future, it is always possible to rid 
the child of his bad habit without leaving serious local damage of 
the sexual organ, or grave, permanent injury of the nervous system. 

The opposite teaching is that peculiar to the advertising quack 
who prophesies every imaginable evil, from complete loss of sexual 



673 SEXUAL HYGIEXE 

function to insanity. Any real or fancied disorder of the sexual 
organs is extremely apt to lead to much mental anxiety and depres- 
sion, so that a cheerful outlook is essential in inspiring effort to cor- 
rect bad sexual habits, and is wholly warranted in view of entire 
recovery in most cases of the young who have abused their sexual 
organs. For it is a sad fact that self-abuse is the rule at some time 
during boyhood on account of the neglect of parents in exercising 
proper supervision over the sexual functions of children. 

The reticence and disinclination of parents to instruct their chil- 
dren in sexual matters can not be too strongly condemned. It is 
natural that youth should wish to know something of the origin of 
life and how human beings come into the world. The mystery and 
concealment thrown around these matters only serve to stimulate the 
curiosity. It is a habit of the parents to rebuke the child for ask- 
ing questions relating to this subject as improper and immodest. The 
first lesson the child learns is to associate the idea of shame with the 
sexual organs. Since he is not enlightened by his proper teachers he 
picks up knowledge where he can get it — which is often from the 
worst possible sources. 

Evasive answers to stave off the dreaded explanation do no good. 
By securing the child's confidence at the start, one may not only keep 
him informed but protect him from seeking or even listening to bad 
counsel. 

Self-abuse is very prejudicial to the character, as there is a ten- 
dency to dwell on impure thoughts and a constant feeble struggle to 
resist the practice and a constant failure to do so. Therefore, when 
the habit is persisted in for a long time there is loss of will power 
and self-reliance, through the shame caused by not resisting the 
sexual desires. But as a matter of fact the practice does not com- 
monly result in permanent injury, as it can be readily stopped if 
taken vigorously in hand, except in the degenerate. As in all other 
diseases an ounce of prevention is worth a pound of cure. 

Prevention of Unhygienic Conditions.— Children at the age of 
three or four should be taught not to touch, handle, rub or irritate 
their sexual organs in any way whatsoever except insofar 
as is necessary in urination or in the course of daily 



SEXUAL HYGIENE 679 

cleansing. Any inclination to do so will usually be found to be 
due to some local trouble to which a physician's attention should 
be called and which may generally be readily remedied by him. It is 
advisable to ask the medical adviser to examine babies after birth for 
the presence of any existing trouble or abnormality of the sexual or- 
gans, as a tight, adherent, or elongated foreskin in boys — and rarely 
a corresponding condition in girls — may give rise to much local irri- 
tation and remote nervous disturbances. The presence of worms 
may lead to irritation in the bowels which excites masturbation in 
children. 

Girl babies should be watched to prevent them from irritating the 
external sexual parts by rubbing them between the inner surfaces of 
the thighs. As the child begins to play with other children he or 
she should be cautioned to avoid those who in any way try to thwart 
the parent's advice, and he or she should be instructed to report all 
such occurrences. Children should not be permitted to sleep to- 
gether at home or when visiting abroad. Those who have acquired 
bad habits should be given a hard bed with light covering and be re- 
quired to arise as soon as they awaken and should not be permitted 
to read in bed before going to sleep. 

A cold bath every morning is recommended ; warm baths often ini- 
tiate the bad habit There should be no pockets in the trousers in 
which the boy may thrust his hands and meddle with his penis. A 
healthy outdoor life is desirable, with swimming and games of all 
kinds. Riding should be discouraged on account of the local irrita- 
tion of the saddle on the oversensitive organs. When the desire to 
masturbate is strong the parts should be bathed in cold water. All 
the thoughts should be wholesome, and companions, books and plays 
conducive to concentration of the ideas on sexual matters are to be 
shunned. Companionship with the opposite sex is not desirable in the 
young. 

At the age of ten or twelve, boys should be instructed by their 
parents or the family physician concerning the harm of self-abuse, 
and should be warned against association with improper companions 
and the reading of filthy literature. The boy should be told that 
absorption of the semen into the blood will make him manly and 



680 SEXUAL HYGIENE 

strong, and it must not be wasted. At fourteen to sixteen years of age 
the boy should be informed of the probability and naturalness of dis- 
charges of semen from the penis during sleep. When these occur 
weekly or at longer intervals they should be considered normal, but 
when they are experienced as frequently as three times a week the 
advice of a physician should be sought. 

The avoidance of alcohol and tobacco, the sleeping on a hard bed 
with light covering, and emptying the bladder before retiring, all tend 
to prevent too great frequency of seminal losses. Sleeping on the 
back favors the occurrence of seminal discharges and it may be 
avoided by wearing a belt about the waist with a knot tied in the 
back. 

At fourteen to sixteen the boy should also be instructed in the 
moral and physical dangers from intercourse with lewd women. 
He should be told that the physical danger is the probability of in- 
fection with gonorrhea and syphilis — one or both ; that there is no way 
by which he can know whether a woman is suffering from these dis- 
eases. That there is not only a probability that he suffer permanent 
disability, should he acquire either of these diseases, but that the 
permanent damage which he may inflict upon other innocent persons 
is incalculable. 

It is generally known that syphilis is a dreadful disease, but not 
perhaps that it endangers the lives and happiness of future genera- 
tions of descendents. Gonorrhea, the much more common disease, 
and often treated lightly by youth, frequently leads to long, chronic, 
local disease or fatal disorder of other parts of the body. Later in 
life it may lead to infection of a wife, resulting in chronic invalidism 
and necessitating the removal of her maternal organs. These occur- 
rences often appear long after the patient thinks he is free from the 
disease (See preceding chapter). 

Gonorrhea is the most frequent cause of sterility in women, and 
indeed of sterility in men, and is also a common source of abortion 
and premature birth. It is the cause of most cases of blindness, in 
infants and also of the inflammation of the external sexual organs 
(vulvovaginitis) in girl babies. It is stated on good authority that 
eighty per cent, of all males suffer from gonorrhea at some time dur- 



SEXUAL HYGIENE 681 

ing their lives. The disease is not confined to prostitutes, but is more 
common in all walks of life and in all classes and ages than is gen- 
erally suspected. The disease is only too frequent in boys' boarding 
schools and similar institutions. 

It is particularly important that the true situation be explained to 
boys about to enter college or business, the period of greatest tempta- 
tion. ISext to bad companions alcohol is their greatest foe. Weak- 
ened by its influence and under the sway of persuasive friends, the 
will gives way and advice and warning are likewise forgotten. 
Idleness is an indirect factor favoring sexual disease, while hard 
physical and mental labor are powerful sedatives to the sexual pas- 
sions. 

Education in sexual hygiene has advanced greatly during the past 
few years and associations of physicians have informed the public 
through lectures to teachers and others, and by pamphlets and special 
instruction in schools, of the prevalence and great dangers of sexual 
diseases. 

When young adult life has been reached, the parent or physician 
should inform the young man or woman as to the dangers of close and 
frequent personal contact with the opposite sex. This applies espe- 
cially to engaged couples who indulge in frequent caresses. Such 
contact involves excitement of the sexual organs and causes in time 
congestion and inflammation of these parts, and is productive of even 
more harm than excessive sexual intercourse. There is no abatement 
of the sexual excitement, as naturally follows sexual intercourse, and 
so the nervous system becomes overwrought and in time there may 
be a complete nervous breakdown. 

Indeed I have known of cases where men's future careers have 
to a considerable degree been ruined by nervous prostration caused 
by long engagements. Long engagements — when the participants 
are frequent companions — are thus decidedly unfortunate. The 
caress with those of the opposite sex is physiologically the first stage 
in sexual intercourse, and if it were looked upon in that light, it would 
certainly be avoided by many of those who now indulge in them by the 
hour and for indefinite periods. 

The symptoms due to continued ungratified sexual excitement 



682 SEXUAL HYGIENE 

include those peculiar to nervous prostration, as mental depression, 
weakness, loss of energy and vitality, pain in the back of the neck, 
etc. ; also symptoms indicating local inflammation of the sexual 
organs, as pain and discomfort about the back part of the urinary pas- 
sage in man, and increased excitability followed by loss of sexual 
power in the course of time. This is another example of great harm 
that often comes to innocent and well-meaning persons through igno- 
rance for which there should be no excuse. The writer knows of a 
young medical man who was a sufferer for years from chronic in- 
flammation of the sexual organs and accompanying nervous break- 
down because of a long engagement, and notwithstanding the fact 
that he was a graduate of one of the leading medical schools of the 
country he had never received any instruction on this shunned sub- 
ject. Ignorance was the sole cause of a long unhappiness and of an 
interference with what would otherwise have been a successful career. 

Young women about to marry should receive instruction from 
physicians or their mothers as to the sexual relations which will exist 
after marriage. Most girls, of the more refined classes, are often 
allowed to grow up wholly ignorant of such matters, and in con- 
sequence become greatly shocked and even disgusted by the sexual 
relations after marriage — fancying that there must be something 
unnatural and wrong about them because the subject was avoided by 
those responsible for the girl's welfare. Such a condition may lead 
to much marital unhappiness. 

In relation to sexual intercourse, no rule as to frequency can be 
laid down. There is as much difference in the sexual powers of dif- 
ferent persons as in muscular power or any other bodily function. 
In a general way it may be said that sexual intercourse is excessive 
for most persons if indulged in more than twice a week. A greater 
frequency in the beginning than this (intercourse twice a week), and 
gradually diminishing frequency in later married life, is the rule. 
Sexual intercourse should be followed by sleep and a feeling of fresh- 
ness. Exhaustion, weariness, headache, loss of appetite, energy, 
ambition, and zest for work ; indigestion, vague pains in the loins, loss 
of interest in society, irritability, indecision, and in women vaginal 
discharge, are some of the symptoms of sexual immoderation. 



SEXUAL HYGIENE 683 

When there is difficulty in restraining the sexual desires, husband 
and wife should occupy separate beds or rooms. 

Intercourse during pregnancy is not harmful if not excessive and 
if it does not occur at the times when the woman would naturally 
menstruate, if not pregnant. Excessive intercourse during pregnancy 
is a common cause of miscarriage. Sexual intercourse is unwise 
during the regular "unwell" periods of women, and in the last month 
of pregnancy, and for one month after childbirth or miscarriage. 

Also in the case of women who have previously miscarried, inter- 
course is inadvisable near the period of the former miscarriage. 
Again, if miscarriage threatens, as shown by the occurrence of flowing 
during pregnancy, there should be a cessation of sexual relations for a 
time. Any deviation from the natural mode of intercourse is pretty 
certain to lead to physical disaster. Thus unnatural prolongation of 
the act or withdrawal on the part of the man before natural com- 
pletion of the act, in order to prevent conception, often results in de- 
plorable nervous disorders in the case of one or both parties. 

The prevention of conception is often as immoral as the destruc- 
tion of the fetus is criminal by means of attempted abortion. At 
times the prevention of conception is proper and justifiable, as when 
the wife is unfit to bear children or has borne too many, or circum- 
stances will not permit of the proper raising of children. There 
is no doubt that race suicide is chiefly due to selfishness and disin- 
clination of parents to undertake the duty of rearing children and 
that it is owing to the use of artificial methods preventing conception 
rather than any failure in the ability to conceive children. Concep- 
tion is most apt to occur when intercourse takes place during the first 
eight days after the cessation of menstruation, and is least prone to 
occur when intercourse is had between the fourteenth and twenty- 
first day after the cessation of menstruation. While conception is 
least apt to follow intercourse during the latter period, still there is 
no time in which conception may not take place. 

It may not be amiss in this place to say a few words concerning the 
honeymoon. The fashion of traveling and sight-seeing is not advis- 
able unless it may be done in a long and leisurely trip. The time 
is one of unusual drain upon the nervous system and a stay in a quiet 



684 SEXUAL HYGIENE 

and secluded country place is preferable to any other. A child is also 
more apt to be delicate when conceived by parents who were at the 
time in a state of exhaustion. It is not unusual also for those visiting 
the gayer resorts to indulge in champagne or other wine during the 
honeymoon to celebrate the happy event, although neither party is an 
habitual user of alcohol. But it may be pointed out here that concep- 
tion is apt to occur at this period, and conception which occurs when 
there is alcohol circulating in the blood of either parent is fraught 
with danger to the offspring. The greatest authorities in the world 
on this subject, Professors Forel and Kraepelin, have shown that the 
offspring of such a conception is subject to neurasthenia, nervousness, 
and unhappiness, if not to genuine mental disease, idiocy, and 
epilepsy. 



CHAPTEK XII 

THE EYE AND EAK 

Foreign bodies in the eye. Black eye. Inflammations of the eyelids. 
Stye. Twitching of the eyelids. Wounds and burns of the eyelids. 
Pink eye. Eye strain. Far- and near-sight. Astigmatism. Strain of 
eye-muscles. Sudden deafness from wax. Deafness from catarrh. 
Foreign bodies in the ear. Severe earache. Abscess of the ear. Slight 
earache. Mastoid inflammation. 



DISEASES OF THE EYE 

CINDERS AND OTHER FOREIGN BODIES IN THE EYE 

Foreign bodies are most frequently lodged on the under surface 
of the upper lid (Fig. 65), although the surface of the eyeball and 
the inner aspect of the lower lid should also be carefully inspected. 

Treatment. — A drop of a two-per-cent. solution of cocain will 
render the manipulations painless. The patient should be directed to 
continue looking downward, and the lashes and edge of the lid should 
be grasped by the forefinger and thumb of 
the right hand, while a very small pencil is 
gently pressed against the upper part of the 
lid, the lower part being lifted outward and 

. . . Fig. 65. — Usual Point of 

upward against the pencil SO that it IS turned Lodgment of Foreign 

• i , mi t i i i . • . i • • Body on the Inner Sur- 

mside out. I he lid may be kept m this posi- FACE OF Upper L n> (a). 
tion by a little pressrue on the lashes, while ? er ? the + lid is turned 

d r 7 inside out. 

the cinder, or whatever foreign body it may 

be, is removed by gently sweeping it off the mucous membrane with 
a fold of a soft, clean handkerchief, or by the aid of a sharp wooden 
toothpick having a little absorbent cotton wrapped over its point. 
Hot cinders and pieces of metal may become so deeply lodged in 

685 




■:-'J THE EYE AXD EAE 

the surface of the eye that it is necessary to dig them out with a needle 
(which has heen passed through a flame to kill the germs on it . fteor 
cocain solution has been dropped into the eye twice at minute inter- 
vals. Such a procedure is, of course, appropriate for an oculist, but 
when it is impossible to secure medical aid for days it can be at- 
tempted without much fear, if done carefully, as more harm will re- 
sult if the offending body is left in place. I: is surprising ;: see how 
quickly a hole in the surface of the eye will fill up in a few days. 
If the foreign body has caused a good deal of irritation before its re- 
moval, it is lest to drop a solution of boric acid (ten grains to the 
ounce of water) into the eye four times daily. 

•BLACK EYE - ' 

To relieve this condition it is necessary _ : treat the eye imme- 
diately after the accident. This can be done by applying to the closed 
lids, every three minutes, little squares of white cotton or linen, 
fourfold and about as large as a silver dollar, that have lain on a cake 
of ice until thoroughly cold. This treatment is most effective when 
pursued almost continuously for hours. The cold compresses should 
d - e permitted to overlap the nose, or a violent cold in the head 
may ensue. 

The swelling having subsided, the discoloration next occupies our 
attention. This may be removed speedily by applying, more or less 
constantly below the lower lid. little pieces of flannel dipped in water 
as hot as can be borne. The cloths must be changed as often as they 
cool. This treatment should be repeated for one-half hour every 
two hours or so during the day. If treatment has not been applied 
the first two days there is no remedy for the discoloration except 
painting the blackened skin a flesh tint with water colors. 

INFLAMMATION OF THE EDGE OF THE EYELIDS 

Blepharitis margin* 

i a condition in which the edges of the eyelids are red : in 
severe cases there is a formation of minute scales on them and loss 
of the evelashes. The condition is often verv chronic. 



DISEASES OF THE EYE 687 

Causes. — It is due in children to poor nutrition, and in adults 
to errors of vision — as astigmatism — which may be corrected by 
glasses. In milder cases there are burning, itching, and smarting of 
the lids, especially after exposure to wind and sun or after constant 
use of the eyes in a bad light. 

Treatment. — An ointment containing one grain of the yellow 
oxid of mercury to one dram of vaselin, rubbed on the lids each 
night on retiring, is most useful. 

But the scales must first be thoroughly removed by bathing the 
lids with warm water, and loose lashes should be pulled out. An 
oculist should be consulted to see if eye strain is not present, which 
could be corrected by glasses ; and the general health of children must 
be improved. 

STYE 

A stye is a boil on the eyelid. It begins at the root of a hair as a 
hard swelling which may extend to the whole lid. The tip of the 
swelling takes on a yellowish color, breaks down, and discharges 
"matter' 7 or pus. There is pain and a feeling of tension in the lid, 
and very rarely, some fever. 

Causes. — The most common cause of styes is inflammation of the 
edges of the eyelids. When one stye follows another it is well to 
have the eyes examined by an oculist, as eye strain often favors the 
trouble, and this can be corrected by the use of glasses. Otherwise 
the patient is probably "run down" from chronic constipation and 
anemia (poverty of the blood) and other causes, and needs a change 
of air, tonics, and exercise out of doors. Kubbing the lids causes 
introduction of pus germs. 

Treatment. — The immediate treatment, which may cut short the 
trouble, consists in bathing the eyelid for fifteen minutes at a time, 
every hour, with a hot solution of boric acid (one-half a teaspoonful 
to each cup of water) . 

Pulling out the eyelash which runs through the stye and touching 
the swelling with a toothpick dipped in tincture of iodin (from which 
the excess has been shaken off) may stop the development if applied 
early. Pushing a sharpened toothpick into the middle of the stye, 
after the former has been moistened with pure carbolic acid, is even 



688 THE EYE AND EAE 

more efficacious, but one must be careful not to have any excess of 
acid on the toothpick to get into the eve. 

If the stye persists in progressing, bathing it frequently in hot 
water will cause it to discharge pus and terminate much sooner. 
After matter has escaped and the stye begins to improve it is best to 
apply the mercury ointment advised in this chapter for inflammation 
of the lids. 

TWITCHING OF THE EYELIDS 

This condition may be due to eye strain, and can be relieved if 
the eyes are fitted to glasses by an oculist (not an optician). 

It is frequently an accompaniment of inflammation of the eyes, 
and when this is cured the twitching of the lids disappears. When 
the eyes are otherwise normal the twitching is frequently one of the 
signs of nerve fag and overwork. 

WOUNDS AND BURNS ABOUT THE EYES 

Treatment for Slight Wounds. — Slight wounds of the inner sur- 
face of the eyelids close readily without stitching, if boric acid solu- 
tion (ten grains to each ounce of water) is dropped into the eye four 
times daily. 

Treatment for Burns of Inner Surface. — Burns of the inner 
surface of the lids follow the entrance of hot water, hot ashes, lime, 
acids, and molten metals. Burns produced by lime are treated by 
dropping milk, sweet oil, or a solution of vinegar (one part of vinegar 
to four of water) into the eye, while those caused by acids are relieved 
by similar treatment with lime water or solution of baking soda (one- 
half a teaspoonful to each glass of water) . If these remedies are not 
at hand, the essential object is attained by washing the eye with a 
strong current of water, as from a fountain syringe. If there is 
much swelling of the lids, and inflammation after the accident, boric- 
acid solution should be dropped into the eye four times daily. 

Treatment of Severe Burns. — In severe burns of the inner sur- 
face of the lids and eyeball vaselin should be kept continuously in 
the eye, or sweet oil or castor oil should be dropped frequently in 
the eye to relieve the pain and prevent the lids from sticking to the 
eyeball. 



DISEASES OF THE EYE G89 

Two grains of atropin sulphate to each ounce of castor oil renders 
it more useful, but no more than a drop of the oil should be dropped 
in the eye after using the boric acid. Treatment by cold compresses, 
as recommended for "black eye," will do much also to quiet the irri- 
tation, and the patient should wear a bandage over the eye or dark 
glasses. 

SORE EYES 

The mucous membrane lining the inner surface of the eyelids 
also covers the front of the white of the eyeball, although so trans- 
parent here that it is not apparent to the observer. Inflammation of 
this membrane is more commonly limited to that portion covering the 
inner surfaces of the lids, but may extend to the eyeball when the 
eye becomes "bloodshot" and the condition more serious. 

For the sake of convenience we may speak of a mild form of 
sore eye, as (a) congestion of the eyelids, and the more severe type, 
as (b) conjunctivitis. 

(a) Congestion of the Eyelids 

Causes. — This may be caused by smoke or dust in the atmosphere, 
or by foreign bodies in the eye; frequently it is due to eye strain, 
or to far- or near-sightedness, astigmatism, or muscular weakness, 
which may be corrected by an oculist's (never an optician's) pre- 
scription for glasses. Exposure to an excessive glare of light, 
as in the case of firemen, or, on the other hand, reading constantly 
and often in a poor light, will induce irritation of the lids. The 
germs which cause "cold in the head" often find their way into 
the eyes through the tear ducts, which connect the inner corner of 
the eyes with the nose, and thus may set up similar trouble in the 
eyes. 

Symptoms. — The eyes feel weary and "as if there w T ere sand in 
them." There may also be smarting, burning, or itching of the 
lids, and there is disinclination for any prolonged use of the eyes. 
The lids, when examined, are found to be much deeper red than 
usual, and slightly swollen; but there is no discharge from the eye, 
and this fact serves to distinguish this mild type of inflammation 



690 THE EYE AND EAR 

from the more severe form, although the lids may have a tendency 
to stick together on waking. 

Treatment. — The use of dark glasses and a few drops of a solu- 
tion, containing ten grains of boric acid and one-half grain of zinc 
sulphate to each ounce of water, in the eye, three times daily, will 
often cure the trouble. Also bathing the eyes in very hot or cold 
water several times daily will usually give much relief. If this 
treatment does not do so within a few days, an oculist should be 
consulted, and it will frequently be found that glasses are needed to 
secure freedom from irritation of the eyes. 

In using "eye drops" the head should be held back, and several 
drops be squeezed from a medicine dropper into the inner comer of 
the eye. 

(b) Conjunctivitis 

(Catarrhal Inflammation of the Eyes) 

Symptoms. — In this disorder there is discharge which sticks the 
lids together during the night. The inner surface of the lids is 
much reddened, the blood vessels in the lining membrane are 
enlarged, and the lids are slightly swollen. The redness may extend 
to the eyeball and give it a bloodshot appearance. There is no inter- 
ference with sight other than momentary blurring caused by the 
discharge, and occasionally there is very severe pain, as if a cinder 
had suddenly fallen in the eye. This symptom may occur at night 
and awaken the patient, and may be the reason for his first consult- 
ing a physician. 

One eye is commonly attacked twenty-four to thirty-six hours be- 
fore the other, and even if it is thought that the cause is a cinder, 
in case of one eye, it can hardly be possible to sustain this belief in 
the case of the involvement of both eyes. There is a feeling of dis- 
comfort about the eyes, and often a burning and constant watering, 
the tears containing flakes of white discharge. 

Causes and Treatment. — When the discharge is a copious, 
creamy pus or "matter," associated with great swelling of the lids 
and pain on exposure to light, the cause is usually a germ of a special 
disease (purulent conjunctivitis) and the eyesight will very prob- 



DISEASES OF THE EYE 691 

ably be lost unless a skillful physician be immediately secured. 
Early treatment is, however, of great service, and, until a physician 
can be obtained, the treatment recommended below should be followed 
conscientiously ; by this means the sight may be saved. 

This purulent variety of inflammation of the eyes is not rare in 
the newborn, and is the usual source of that form of blindness with 
which babies are commonly said to have been born. It can be pre- 
vented by dropping a two per cent, solution of silver nitrate in each 
eye of the newborn infant — and this is the rule with the careful 
doctor. 

All forms of severe inflammation of the lids are contagioas, espe- 
cially the variety last considered, and can be conveyed, by means of 
the discharge, through the agency of towels, handkerchiefs, soap, 
wash basins, etc., and will produce the same or sometimes different 
types of inflammation in healthy eyes. Therefore, if the severe 
form of conjunctivitis breaks out among any large number of people, 
as in schools, prisons, asylums, and almshouses, isolation of the pa- 
tients should be enforced. 

In the milder attacks of conjunctivitis the treatment should be 
that recommended above for congestion of the lids. The swelling and 
inflammation, in the severer types, are greatly relieved by the appli- 
cation of the cold water compresses, advised under the section on 
"Black Eye/' for an hour at a time, thrice daily. Confinement in a 
dark room, or the use of dark glasses, and drops of zinc sulphate solu- 
tion (one-half grain in an ounce of water) three times a day, with 
hourly dropping of boric acid (ten grains to each ounce of water) 
constitute the ordinary treatment. If this treatment is not promptly 
efficacious, one may drop a freshly prepared ten per cent, solution 
of argyrol into the eyes three times daily, in place of the boric acid 
and zinc sulphate solutions. 

In inflammations with copious discharge of creamy pus, and great 
swelling of the lids, the eyes should be washed well with the boric 
acid solution every half hour, and a solution of silver nitrate (two 
grains to each ounce of water) dropped into the eye, once daily, 
followed immediately by a weak solution of common salt in water to 
neutralize the nitrate of silver, after its action has been secured. Or 



692 THE EYE AND EAR 

a fresh solution (fifty per cent.) of argyrol is often now used, in 
place of the silver nitrate, as it is not irritating, and may be used 
three times daily. The constant use of ice cloths, already mentioned 
(under Black Eye), forms a necessary adjunct of treatment. 

The sound eye must be protected from the chance of contagion, 
arising from a possible infection from the pus discharging from its 
mate. This may be secured by bandaging the well eye, or, better, by 
covering it with a watch crystal kept in place by surgeon's plaster, 

In treating sore eyes with discharges, in babies, the patient should 
be held in the lap with his head backward and inclined toward the 
side of the sore eye, so that in washing the eye no discharge will 
flow into the sound eye. The boric acid may then be dropped from 
a medicine dropper, or applied upon a little wad of absorbent cotton 
to the inner corner of the eye, while the eyelids are held apart. 

Hemorrhages occurring under the conjunctiva (or membrane lin- 
ing the inner surface of the lids and covering the front surface of 
the white of the eyeball) may be caused by blows or other injury to 
the eye, by violent coughing, by straining, etc. Dark-red spots may 
appear in the white of the eyeball, slightly raised above the surface, 
which are little blood clots under the conjunctival membrane. ~No 
special trouble results, and there is nothing to be done except to wait 
until the blood is absorbed, which will happen in time. If the eyes 
water, solution of zinc sulphate (one-half grain to ounce of water) 
may be dropped into the eye, twice daily. Hot applications are bene- 
ficial here to promote absorption of the clot. 

"PINK EYE" 

Causes. — This is a severe epidemic form of catarrh of the eye, 
which is caused by various special germs, more often the germs of 
pneumonia and the so-called Week's bacillus, also by the ordinary 
germs causing inflammation of wounds (streptococci and staphylo- 
cocci). 

"Catching cold," chronic nasal catarrh, exposure to foul vapors 
and gases, or tobacco smoke, and the other causes enumerated, as 
leading to congestion of the lids, are also responsible for catarrhal 
inflammation of the eye. 



DISEASES OF THE EYE 



693 



Treatment. — The treatment of this is the same as outlined above 
under Conjunctivitis. 

EYE STRAIN 

Eye strain is commonly due either to astigmatism, nearsighted- 
ness, farsightedness, or weakness of the eye muscles. 

The farsighted eye is one in which parallel rays entering the 
eye, as from a distance, come to a focus behind the retina (Fig. 66). 




Fig. 66. — Farsighted (Hyperopic) Eye Focusing Parallel Rays of Light Behind 
the Retina at f. A Convex Glass (1) is Required to Converge the Rays (Dot- 
ted Line) so that They Will Focus Exactly on the Retina at r. 



The retina is the sensitive area for receiving light impressions in the 
back of the eyeball. Sight is really a brain function ; one sees with 
the brain, since the optic nerve endings in the back of the eye (retina) 
merely carry light impressions to the brain where they are properly 
interpreted. 

In order that vision be clear and perfect, it is essential that the 
rays of light enter- 
ing the eye be bent 
so that they strike 
the retina as a single 
point (Fig. 67). In 
the farsighted or 
hyperopic eye, the 
eyeball is usually too 
short for the rays to 
be properly focused on the sensitive nerve area in the back of the 
eye. A farsighted eye is one smaller than it should be — an undevel- 
oped eye. Parallel rays from distant objections are focused better 
than converging rays from near objects as shown in Figure 68, 
where h. h. are the parallel rays, and N" rays from a near object. 




Fig. 67. 



-Focusing of Light Rays in a Normal 
(Emmetropic) Eye. 



694 



THE EYE AND EAE 



This defect in vision is, however, overcome by the act of "accom- 
modation." There is a beautiful transparent, double-convex body, 



N-~'V 




-—-b 



Fig. 68. — Farsighted (Hyperopic) Eye Showing the Focusing of Rays from Near 
(n) and Far Objects (h) Behind the Retina. 



about one-third of an inch thick, which looks very much like an ordi- 
nary glass lens, and is situated in the eye just back of the pupil. This 
is what is known as the crystalline lens, and the rays of light are bent 



CORNEA 




CONJUNCTIVA 
ANTERIOR 
CHAMBER 



CILIARY 
MUSCLE 



RETINA 



OPTIC NERVE 



Fig. 69. — During Accommodation the Lens Becomes More Convex Through Con- 
traction of the Ciliary Muscle, as Shown in the Left of the Diagram, while 
to the Right of the Line Drawn Through the Eye is Shown the Position of 
the Lens at Rest. 



in passing through it so as to be properly focused on the retina (See 
Fig. 69). 

The foregoing statements have been made as though objects were 
always at a distance from the eye, so that the rays of light coming 



DISEASES OF THE EYE 695 

from them were almost parallel. Yet when one is looking at an 
object within a few inches of the eye the rays diverge or spread out, 
and these the normal eye (if rigid) could not focus on the retina — 
much less the farsighted eye. But the eye is adaptable to change of 
focus, through the action of the ciliary muscle which controls to a con- 
siderable extent the shape of the lens, and is situated within the eye- 
ball surrounding the lens. 

When the ciliary muscle contracts it allows the lens to bulge 
forward by virtue of its elasticity, and, therefore, to become more 
convex. This is what happens when one looks at near objects, the 
increased convexity of the lens bending the rays of light so that they 
will focus as a point on the retina. 

Now in the farsighted eye this muscular control or "accommo- 
dative action" must be continually exercised even in looking at dis- 
tant objects, and it is this constant attempt of nature to cure an 
optical defect of the eye which frequently leads to nervous exhaustion 
or eye strain. The nerve centers, which animate and control the 
nerves supplying the eye muscles to which we have just alluded, are 
in close proximity to other most important nerve centers in the brain, 
so that the irritation of the eye centers will produce sympathetic irri- 
tation of these other centers, leading to manifold and complex symp- 
toms which we will describe under symptoms of eye strain. But 
these symptoms do not necessarily develop in every one having far- 
sightedness or astigmatism, since both are often present at birth. 

The power of accommodation is sufficient to overcome the optical 
defect of the eye, providing that the general health is good and the 
eye is not used much for near work. If, on the other hand, exces- 
sive use of the eyes in reading, writing, figuring, sewing, or other 
fine work is required, and especially if the health becomes impaired, 
it happens that the constant drain on the eye center in the brain 
will result in a group of symptoms which we will consider later. 
Failure of accommodation comes on at about forty, and gradually in- 
creases until all accommodation is lost, at the age of seventy-five. 

For this reason it is necessary for persons over forty-five years of 
age, having normal or farsighted eyes, to wear convex glasses in read- 
ing or doing near work, and these should be changed for stronger 



696 THE EYE AND EAR 

ones every year or two. These convex glasses save the eyes in their 
attempts to make the lens more convex when looking at near objects 
in farsightedness, and also prove serviceable in the same manner 
when accommodation begins to fail in the case of what is called "old 
sight." Neglect to provide proper glasses for reading at any time 
after the age of forty-five, and the failure to replace them by stronger 
lenses when required, distinctly favor the occurrence of cataract in 
later life. 

In the act of accommodation, in addition to the muscular action 
by which the lens is made more convex, there is usually contraction 
of another group of muscles outside the eyeball, which turn the eyes 
inward when they are directed toward a near object. Here then 
is another source of trouble resulting from farsightedness, i. e., the 
not infrequent occurrence of inward "squint" occasioned by the 
constant use of the muscles pulling the eyes inward during accommo- 
dation for near objects. Again, inflammation of the eyelids, and 
sometimes of deeper parts of the eyeball, follows untreated hyperopia 
(farsightedness). Early distaste for reading is often acquired by 
farsighted persons, owing to the strain on the accommodative appa- 
ratus. The convex lens is that used to correct farsightedness {See 
Fig. 66. 

Nearsighted Eye. — In the nearsighted eye the eyeball is too 
long for parallel rays entering the eye to be focused upon the retina ; 
they are bent, instead, to a point in front of the retina, and then 
diverge, making the vision blurred. The act of accommodation in 
making the lens more convex will not aid this condition but only 
make it worse, so that it-is not attempted. 

Eye strain in this optical defect is brought on by constant use 
of the eye muscles (attached to the inner surface of the outside of 
the eyeball) in directing both eyes inward so that they will both 
center on near objects — the only ones which can be seen. Outward 
squint frequently results, because the muscular efforts required to 
direct both eyes equally inward to see near objects are so great that 
the use of both eyes together is given up, and the poorer eye is not 
used and squints outward, while the better eye is turned inward in 
the endeavor to see. 



r *-^-_ 




DISEASES OF THE EYE 697 

Nearsighted persons are apt to stoop, owing to the habitual neces- 
sity for coming close to the object looked, at. Their facial expres- 
sion is also likely to be rather vacant, since they do not distinctly see, 
and do not respond to the facial movements of others. 

Nearsightedness, or myopia, is not a congenital defect, but is 
usually acquired, owing to excessive near work which requires that 
the eye muscles constantly direct both eyes inward to* see near 
objects. In so acting the muscles compress the sides of the eyeballs 
and tend to increase their length, interfere with their nutrition, and 
aggravate the con- 
dition when it is _L 
once begun. Con- 
cave lenses are used 
to correct myopia, 
and they must be 

Worn all the time. Fig. 70. — Nearsighted or Myopic Eye Focusing Paral- 

i lel Rays from a Distant Object at f in Front of 

ASTIGMATISM. the Retina. A Concave Lens (1) Will Cause Paral- 

— This is a condi- IiEL ^ AYS TO Diverge, as from a Near Object (r); and 

so Focus Exactly on the Retina as at b. 

tion caused by in- 
equality of the outer surface of the front of the eyeball, and rarely 
by a similar defect in the surfaces of the lens. The curvature of the 
eyeball in the astigmatic eye is greater in one meridian than in the 
opposite; in other words, the front of the eyeball is not regularly 
spherical, but bulges along a certain line or meridian, while the 
curvature is flattened or normal in the other meridian. Eor instance, 
if two imaginary lines were drawn, one vertically and the other hori- 
zontally across the front of the eyeball, intersecting in the center of 
the pupil, they would represent the principal meridians — the vertical 
and the horizontal. As a rule the meridian of greatest curvature is 
approximately vertical, and that of least curvature is at right angles 
to it, or horizontal. 

Rays of light in passing through the different meridians of the 
astigmatic eye are differently bent, so that in one of the principal 
meridians rays may focus perfectly on the retina, while in the other 
the rays may focus on a point behind the retinal field. In this 
case the eye is made farsighted or hyperopic in one meridian, and 



698 



THE EYE AND EAR 




r.-h' 



Fig. 71. — Simple Hyperopic Astigmatism. 
The Rays h. h. Pass through the Vertical or 
Hyperopic Meridian and are Focused Behind 
the Retina at h'. 



is normal in the other. Or again, the rays may be focused in front 
of the retina in one meridian, and directly on the retina in the other ; 
this would be an example of nearsighted or myopic astigmatism. 

Farsightedness and nearsightedness are then both caused by astig- 
matism, although in this case not by the length of the eyeball, but by 
inequality in the curvature of the front part (cornea) of the eyeball. 

For example, in simple astig- 
matism one of the principal 
meridians is hyperopic (turn- 
ing the rays so that they 
focus behind the retina) or 
myopic (bending the rays so 
that they focus in front of 
the retina, while the other 
meridian is normal). In mixed astigmatism, one of the principal 
meridians is myopic, the other hyperopic ; in compound astigmatism 
the principal meridians are both myopic, or both hyperopic, but differ 
in degree; while in irregular astigmatism, rays of light passing 
through different parts of the outer surface of the eyeball are turned 
in so many various directions that they can never be brought to a 
perfect focus by glasses. 

It is not by any means possible for 
a layman to be able always to inform 
himself that he is astigmatic, unless the 
defect is considerable. If a card, on 
which are heavy black lines of equal 
size and radiating from a common cen- 
ter like the spokes of a wheel, be placed 

on a wall in good light, it will appear to the astigmatic eye as if cer- 
tain lines (which are in the faulty meridian of the eyeball) are 
much blurred, while the lines at right angles to these are clear and 
distinct. Each eye should be tested separately, the other being 
closed. The chart should be viewed from a distance as great as any 
part of it can be seen distinctly. All the lines on the test card should 
look equally black and clear to the normal eye. 

Astigmatism is corrected by a cylindrical lens, which is in fact a 




Fig. 72. — Simple Hyperopic As- 
tigmatism Shown in Fig. 95, 
Corrected by a Convex Cyl- 
indrical Glass. 



DISEASES OF THE EYE 699 

segment of a solid cylinder of glass. The axis of the cylindrical lens 
should be at right angles to the defective meridian of the eye, in 
order to correct the astigmatism (Figs. 71 and 72). 

Eye strain is caused by astigmatism in the same manner that it 
is brought about in the simple farsighted eye, i. e., by constant strain 
on the ciliary muscle, which regulates the convexity of the crystalline 
lens. For it is possible for the inequalities of the front surface of 
the eyeball, or of the lens, to be offset or counterbalanced by change in 
the convexity of the lens produced by the action of this muscle, and it 
is conceivable that the axis of the lens may be tilted one way or an- 
other by the same agency, and for the same purpose. But, as we have 
already pointed out, this continual muscular action entails great 
strain on the nerve centers which animate the muscle, and if constant 
near work is requisite, or the health is impaired, the nervous ex- 
haustion becomes apparent. The lesser degrees of astigmatism often 
give more trouble than the greater. 

Weakness of the Eye Muscles. — There are six muscles at- 
tached to the outside of the eyeball (Fig. 73) which pull it in various 
directions, and so enable each eye to be directed upon a common 
point — otherwise objects will appear double. Weakness of these 
muscles or insufficiency, especially of those required to direct the 
eyes inward for near work, may lead to symptoms of eye strain. 
When reading, for example, the muscles which pull the eye inward 
soon grow tired and relax, allowing the opposing muscles to pull the 
eye outward so that the eyes are no longer directed toward a com- 
mon point, and two images may be perceived or, more frequently, 
they become fused, producing a general blurring on the page. Then 
by a new effort of will the internal muscles pull the eyes into line 
again, only to have the performance repeated — all of which entails 
a great strain upon the nervous system, and may lead to permanent 
squint, as has been pointed out. In addition to these symptoms 
caused by weakness of the eye muscles — seeing double, blurred vision, 
and want of endurance for close work — there are others which are 
common to eye strain in general, as headache, nausea, etc., described 
in the following paragraph. 

Symptoms of Eye Strain. — -Headache is the most frequent 



700 



THE EYE AXD EAR 



symptom. It may be about the eyes, but there is no special character- 
istic which will positively enable one to differentiate an eye headache 
from that arising from other sources, although eye strain is probably 
the most common cause of headache. Persons with habitual or fre- 
quent headaches should, as a matter of routine, have their eyes tested 
by an able oculist (not an optician). 

The headache resulting from eye strain may then be in the fore- 
head, temples, top or the back of the head, or limited to one side. It 
frequently takes the form of "sick headache." It is perhaps more 



INTERNAL RECTUS 
MUSCLE 




EYE LID 



OPTIC NERVE 



EYELID 



INFERIOR 
OBLIQUE MUSCLE 

Fig. 73. — Outside of the Eyeball. 



apt to appear after any unusual use of the eyes in reading, writing, 
sewing, riding, shopping, or sight-seeing, and going to theaters and 
picture galleries, but this is not by any means invariably the case, 
as eye headache may appear without apparent cause. 

Nausea and vomiting, with or without headache, nervousness, 
sleeplessness, and dizziness, often accompany eye strain. Sometimes 
there is weakness of the eyes, i. e., lack of endurance for eye work, 
twitching of the eyelids, weeping, styes, and inflammation of the lids. 

In view of the extreme frequency of eye disorders which lead to 
eye strain, it behooves people, in the words of an eminent medical 
writer, to recognize that "the subtle influence of eye strain upon 
character is of enormous importance" inasmuch as "the disposition 
may be warped, injured, and wrecked,'' especially in the young. 



DISEASES OF THE EYE 701 

Some of the more serious nervous diseases — as nervous exhaus- 
tion, convulsions, hysteria, and St. Vitus's dance — may be caused by 
the reflex irritation of the central nervous system following eye strain. 

Treatment of Eye Strain. — The essential treatment of eye 
strain consists in the wearing of proper glasses. It should be a rule, 
without any exception, to consult a competent oculist — and never 
an optician — for the selection of glasses. It is as egregious a piece 
of folly to employ an optician to choose the glasses as it would be to 
seek an apothecary's advice in a general illness. Considerably more 
damage would probably accrue from following the optician's prescrip- 
tion than that of the apothecary, because nature would soon offset 
the effects of an inappropriate drug ; but the damage to the eyes from 
wearing improper glasses would be lasting. 

Properly to determine the optical error in astigmatic and far- 
sighted eyes it is essential to place drops in the eye, which dilate 
the pupil and paralyze the muscles that control the convexity of the 
crystalline lens, and to use instruments and methods of examination, 
which can only be properly undertaken and interpreted by one with 
the general and special medical training possessed by an oculist. 

The statement has been emphasized that farsighted and astigmatic 
persons, up to the age of forty-five or fifty, can sometimes overcome 
the optical defects in their eyes by exercise of the ciliary muscle 
which alters the shape of the lens, and therefore, it would be im- 
possible for an examiner to discover the fault without putting drops 
in the eye, which temporarily paralyze the ciliary muscles for from 
thirty-six to forty-eight hours, but otherwise do no harm. After 
the age of fifty it may be unnecessary to use drops, as the muscular 
power to alter the convexity of the lens is greatly diminished. 

Opticians are incompetent to employ these drops, as they may do 
great damage in certain conditions of the eye which can only be de- 
tected by a medical man specially trained for such work. Opticians 
are thus sure to be caught on one of the horns of a dilemma ; either 
they do not use drops to paralyze the ciliary muscle, or, if they 
do employ the drops, they may do irreparable damage to the eye. 

Any abnormality connected with the vision, especially in chil- 
dren, should be a warning to consult an oculist. Squint, "cross-eye" 



702 THE EYE AND EAE 

(strabismus), as has been stated, may often result from near- or far- 
sightedness, and it may be possible in young children to cure the 
squint by the use of glasses or even drops in the eye, whereas in later 
life it may be necessary to cut some of the muscles of the eyeball to 
correct the condition. It is a wise rule to subject every child to an 
oculist's examination before entering upon school life. 



DISEASES OF THE EAR 

« 

DEAFNESS 

Sudden deafness without apparent reason is more apt to result 
from an accumulation of wax than from any other cause. It is a 
very common ear disorder. 

The opening into the ear is about an inch long, or a little more, 
and is separated from that part of the ear within, which is known 
as the middle ear, by the ear drum membrane. The drum membrane 
is a thin, skinlike membrane stretched tightly across the inner end 
of the external opening in the ear, or auditory canal, and shuts it 
off completely from the middle ear within, in this way protecting the 
middle ear from the entrance of germs, dust, and water, but only 
secondarily aids in hearing. The obstruction caused by wax usually 
exists in about the middle of the auditory canal or opening in the 
ear, and only causes deafness when it completely blocks this passage. 

The deafness is sudden, because, owing to the accidental entrance 
of water, the wax quickly swells and chokes the canal ; or, in at- 
tempts to relieve irritation in the ear, the finger or some other object 
is thrust into the opening in the ear (auditory canal) and presses the 
wax down on the ear drum. The obstruction in the ear is usually 
a mixture of waxy secretion from the canal, and little scales of dead 
skin which become matted in unwise efforts at cleansing the ear by 
introducing a twisted towel or some other object into the ear passage 
and there turning it about ; or it may occur owing to disease of the 
ear altering the character of the natural secretion. 

In the normal state, the purpose of the wax* is, apparently, to 
repel insects and to glue together the little flakes of cast-off skin 



DISEASES OF THE RAH 703 

in the auditory canal, and these, catching on the hairs lining the 
canal, are thrown out of the ears upon the shoulder by the motion 
of the jaws in eating. 

Nothing should be introduced into the ear with the idea of cleans- 
ing it, as the skin growing more rapidly from within tends naturally 
to push the dead portions out as required, and so the canal is self- 
cleansing. 

Symptoms. — Sudden deafness in one ear usually calls the atten- 
tion of the patient to an accumulation of wax. There is apt to be 
more or less wax in the other ear as well. 

Noises in the deaf ear and a feeling of pressure are also common ; 
among rarer symptoms are nausea and dizziness. The only way to 
be sure that deafness is due to choking of the air passages with wax 
is to see the wax. This is usually accomplished by a physician by 
throwing a good light from a mirror into a small tube introduced 
into the ear passage. This procedure is of course impossible for a 
layman, but if the ear is drawn upward, backward, and outward, 
so as to straighten the canal, it may be possible for anyone to see a 
mass of yellowish-brown or blackish material filling the passage. 
And, in any event, if the wax cannot be seen, one is justified in treat- 
ing the case as if it were present — if sudden deafness has occurred 
and competent medical aid is unobtainable — since no harm will be 
done if wax is absent, and, if it is present, the escape of wax will 
usually give immediate relief from deafness and other symptoms. 

Treatment. — The wax is to be removed with a syringe and water 
as warm as can be borne comfortably. A hard-rubber syringe having 
a piston, and holding as much as possible, is to be employed. 

The clothing of the patient should be protected by towels placed 
around the neck and under the deaf ear. A basin is also held under 
the ear to catch the water flowing out of the canal. The tip of 
the syringe is introduced just within the entrance of the ear, which 
is to be pulled backward and upward, and the stream of water is to 
be directed with considerable force against the upper and back part 
of the passage, rather than directly down upon the wax. The water 
which is first returned is discolored, and then, on repeated syringing, 
little flakes of dry skin, with perhaps some wax adhering, may be 



704 THE EYE AND EAR 

seen floating on top of the water which flows from the ear, and finally, 
after a longer or shorter period, a plug of wax becomes dislodged, 
and the whole trouble is over. 

This is the rule, but sometimes the process is very long and 
tedious, only a little wax coming away at a time; rarely, dizziness 
and faintness will require the patient to lie down for a while. The 
water should always be removed from the ear, after syringing, by 
twisting a wisp of absorbent cotton about the end of a toothpick or 
match (which has first been dipped in water to make the cotton ad- 
here). The tip of the match, thus being thoroughly protected by 
dry cotton applied so tightly that there is no danger of it slipping 
off, is gently pushed into the bottom of the canal and removed (while 
the ear is pulled backward and upward to straighten the canal). The 
ear is thus to be wiped out repeatedly with fresh cotton wool until 
the cotton returns dry. Finally a pledget of cotton should be loosely 
packed in the ear passage and worn by the patient for twelve to 
twenty-four hours. 

Persistent and Chronic Deafness 
A consideration of deafness requires some understanding of the 
structure and relations of the ear with other parts of the body, notably 
the throat. It has been pointed out that the external ear — compris- 
ing the fleshy portion of the ear, or auricle, and the opening, or ca- 
nal, about an inch long — is separated from that portion of the ear 
within (or middle ear) by the drum membrane. The middle ear,, 
while protected from the outer air by the drum, is really a part of 
the upper air passages, and participates in disorders affecting them. 
It is the important part of the ear as it is the seat of most ear trou- 
bles, and disease of the middle ear not only endangers the hearing, 
but threatens life through proximity to the brain. 

In the middle ear we have an air space connected with the 
throat by the eustachian tube, a tube about an inch long running 
downward and forward to join the upper air passage at the junction 
of the back of the nose and upper part of the throat. If one should 
run the finger along the roof of the mouth and then hook it up 
behind and above the soft palate one could feel the openings of these 



DISEASES OF THE EAR 705 

tubes (one for each ear) on either side of the top of the throat or back 
of the nose, according to the view we take of it. 

Then the middle ear is also connected with a cavity in the 
bone back of the ear (mastoid cavity or cells), and the outer and 
lower wall is formed by the drum membrance. Vibrations started 
by sound waves which strike the ear are transmitted by means of a 
chain of three little bones from the drum through the middle ear to 
the nervous apparatus in the internal ear. The head of one of these 
little bones may be seen by an expert, looking into the ear, pressing 
against the inside of the drum membrane. Stiffening or immova- 
bility of the joints between these little bones, from catarrh of the 
middle ear, is most important in producing permanent deafness. 
The middle ear space is lined with mucous membrane continuous 
with that of the throat through the eustachian tube. This serves to 
drain mucus from the middle ear, and also to equalize the air pres- 
sure on the ear drum, so that the pressure within the middle ear 
shall be the same as that without. 

When there is catarrh or inflammation of the throat or nose it 
is apt to extend up the eustachian tubes and involve the middle ear. 
In this way the tubes become choked and obstructed with the over- 
secretion or by swelling. The air in the middle ear then becomes 
absorbed in part, and a species of vacuum is produced with increased 
pressure from without on the ear drum. The drum membrane will 
be pressed in, and through the little bones pressure will be made 
against the sensitive nervous apparatus, irritating it and giving rise 
to deafness, dizziness, and the sensation of noises in the ear. Noises 
from without will also be intensified in passing through the middle 
ear, when it is converted into a closed cavity through the blocking 
of the eustachian tube. 

A very important feature following obstruction of the eustachian 
tubes, and rarefaction of the air in the middle ear, is that conges- 
tion of the blood vessels and increased secretion ensues, because the 
usual pressure of the air on the blood vessels within the middle ear 
is taken away. 

Causes. — Chronic catarrh of the nose and throat is the cause of 
most permanent deafness, to which is given the name catarrhal deaf- 



706 THE EYE AXD EAE 

ness, because every fresh cold in the head, or sore throat, tends to 
start up trouble in the ear such as we have just described. Repeated 
attacks leave vestiges behind until permanent deafness remains. 

In normal conditions every act of swallowing opens the apertures 
of the eustachian tubes in the throat, and allows of equalization of 
the air pressure within and without the ear drum, but if the nose 
is stopped by a cold in the head or enlargement of the tissue at the 
back of the nose fas from adenoids), the process is reversed and air 
is exhausted from the eustachian tubes with each swallowing motion. 

Prevention.- — The moral to be drawn from all the foregoing is 
to treat colds properly when they are present, keeping the nose and 
throat clean and clear of mucus, and to have any abnormal obstruc- 
tion in the nose or throat and source of chronic catarrh removed, as 
enlarged tonsils, adenoids, and nasal outgrowths. 

FOREIGN BODIES IN THE EAE, 

Foreign bodies, as buttons, pebbles, beans, corn, cherry stones, 
coffee, seeds, etc., are frequently placed in the ear by children; in- 
sects sometimes find their way into the ear passage and create tremen- 
dous distress by their struggles. Smooth, non-irritating bodies, as 
buttons, pebbles, etc., do no particular harm for a long time, and may 
remain unnoticed for years. But the most serious damage not in- 
frequently results from unskillful attempts at their removal by per- 
sons (even physicians unused to instrumental work on the ear) who 
are driven to immediate and violent action on the false supposition 
that instant interference is called for. 

Treatment. — Insects, it is true, should be killed without delay by 
dropping sweet oil, castor oil, linseed, machine oil, glycerin, or even 
water, into the ear if the others are not at hand, and then the insect 
should be removed in half an hour by syringing as recommended 
for wax in the ear. 

To remove solid bodies, turn the ear, containing the body, down- 
ward, pull it outward and backward, and rub the skin just in front 
of the opening into the ear with the other hand, and the object may 
fall out. 

Failing in this, syringing with warm water, as for removal of 



DISEASES OF THE EAR 707 

wax, while the patient is sitting, may prove successful. The essen- 
tials of treatment then consist, first, in keeping cool ; then in killing 
insects by dropping oil or water into the ear, and, if syringing proves 
ineffective, in using no instrumental methods in an attempt to re- 
move the foreign body, but in awaiting such time as skilled medical 
services can be obtained. If beans or seeds are not washed out by 
syringing, the water may cause them to swell and produce pain. To 
obviate this, drop alcohol — which absorbs water — in the ear and it 
will thus shrivel the seed. 

EARACHE 

Earache is due usually not to neuralgia of the ear, but to a true 
inflammation of the middle ear, which either subsides or results in 
the accumulation of inflammatory products until the drum is rup- 
tured and discharge occurs from the external canal. The trouble 
commonly originates from an extension of catarrhal disease of the 
nose or throat, the germs which are responsible for these disorders 
finding their way into the eustachian tubes, and thus into the middle 
ear. Any source of chronic catarrh of the nose or throat — as enlarged 
and diseased tonsils, adenoids in children, or nasal obstruction — 
favors the growth of germs and the occurrence of frequent attacks of 
acute catarrh or "colds." 

The grippe has been the most fruitful cause of middle-ear inflam- 
mation and earache in recent years. Any act which forces up fluid 
or secretions from the back of the nose into the eustachian tubes 
(See Section on Deafness) and thus into the middle ear, is apt to set 
up inflammation there, either through the introduction of germs, or 
owing to the mechanical injury sustained. It follows for this reason 
that the act of sniffing water into the nose, or blowing the nose 
violently when there is secretion or fluid in the back of the nose, or 
the employment of the postnasal syringe are one and all attended 
with this danger. 

Swimming on the back, diving, or surf bathing also endanger the 
ear, as cold water is forcibly driven not only into the external audi- 
tory canal, but, what is more frequently a source of damage, into the 
eustachian tubes through the medium of the nose or throat. 

In this case the plugging of the nose with cotton would be of more 



708 THE EYE AND EAE 

value than the external canal, as is commonly practiced. If water 
has entered the eustachian tube, blowing the nose and choking merely 
aggravate the trouble. The wiser plan is to do nothing but trust that 
the water will drain, and if pain ensues treat it as recommended 
below for severe earache. 

Water in the ears is sometimes removed by jumping about on one 
foot with the troublesome ear held downward, and if it is in the 
external canal it may be wiped out gently with cotton on the end of 
a match, as recommended in the article on treating wax in the ear. 
In treatment of catarrh in the nose or throat only a spray from an 
atomizer should be used, as Dobell's or Seilers solution followed 
by menthol and camphor, ten grains of each to the ounce of al- 
bolene or liquid vaselin by means of a medicine dropper. 

Exposure to cold and the common eruptive diseases of children — 
as scarlet fever, measles, and also diphtheria — are common causes 
of middle-ear inflammation. In the latter disorders the protection 
afforded by a nightcap which comes down over the ears, and worn 
constantly during the illness, is frequently sufficient to ward off ear 
complications. 

Symptoms of Inflammation of the Middle Ear. — Pain is severe 
and often excruciating in adults. It may be felt over the temple, 
side, and back of the head and neck, and even in the lower teeth, 
as well as in the ear itself. The pain is increased by blowing the 
nose, sneezing, coughing, and stooping. There is considerable tender- 
ness usually on pressing on the skin in front of the ear passage. 
Some deafness and noises in the aching ear are usual. 

In infants there may be little evidence of pain in the ear. They 
are apt to be very fretful, refuse food, cry out in sleep, often lie with 
the affected ear resting on the hand, and show tenderness on pres- 
sure immediately in front or behind the ear passage. 

Dullness, fever, chills, and convulsions are not uncommon in chil- 
dren, but, on the other hand, after some slight illness it is not infre- 
quent for discharge from the ear to be the first sign which calls the 
attention of parent or medical attendant to the source of the trouble. 
For this reason the careful physician will always examine the ear 
in doubtful cases of children's diseases. 



DISEASES OF THE EAR 709 

Unless the inflammation subsides with treatment, either a thin, 
watery fluid (serum) is formed in the middle ear, or pus, in which 
case we have an "abscess of the ear." The drum, if left to itself, 
breaks down in three to five days, or much sooner in children who 
possess a thinner membrane. A discharge then appears in the canal 
of the external ear, and the pain is relieved. It may occasionally 
happen that the eustachian tube drains away the discharge, or that 
the discharge from the drum is so slight that it is not perceived, and 
recovery ensues. Discharge from the ear continues for a few weeks, 
and then the hole in the drum closes and the trouble ceases. 

This is the history in favorable cases, but unfortunately the oppo- 
site state of affairs results not infrequently, especially in neglected 
patients. 

Although earache or middle-ear inflammation is common, its dan- 
gers are not fully appreciated, since various complications are 
likely to arise, and the result is not rarely serious. Extension of 
the inflammation to the mastoid cells or the bone behind the ear 
(mastoid abscess) may necessitate chiseling away a part of the skull 
to liberate pus or dead bone in this locality, and the occurrence of 
abscess of the brain will necessitate operation. 

Treatment of Severe Earache. — It is wise for the patient to take 
a rapidly acting cathartic at the outset, such as a heaping tablespoon- 
ful of Epsom salts, for an adult, or one or two grains of calomel for 
a child. He should go to bed and lie all the time with the painful 
ear on a bag containing water as hot as can be comfortably borne. 
Every two hours a jet of hot water, which has been boiled and cooled 
sufficiently to permit of its use, should be allowed to flow gently from 
a fountain syringe into the ear for ten minutes and the ear then 
dried with absorbent cotton, as described under the treatment of 
wax in the ear. 

It may not be possible to carry out such treatment, and in that 
case one may drop one-quarter of a teaspoonful of a ten per cent, 
solution of carbolic acid in glycerin (warmed) in the ear, but this 
treatment is not to be repeated. 

The application of leeches in the beginning of the attack is of 
value and not in any way painful. One should be applied just in 



710 THE EYE AND EAE 

front of the opening of the ear (which should first be closed with 
absorbent cotton to prevent the entrance of the leech), one just be- 
low the ear on the neck, as close to the ear as possible, and a third 
in the crease behind the ear where it joins the head and at the level 
of the opening into the ear. A drop of milk at these points will 
usually start the leeches to work and when they are gorged with 
blood and cease to suck they should be removed, and bleeding should 
be encouraged by applying hot compresses of absorbent cotton to 
these places for half an hour longer. Then clean dry, absorbent 
cotton should be applied and pressure made with a bandage to stop 
further bleeding. 

The aftertreatment of the bites consists in cleanliness and the use 
of vaselin. Ten drops of laudanum 1 for an adult, or a teaspoonful of 
paregoric 1 for a child, may be given by the mouth, to relieve the 
pain. The patient should stay in bed with the ear on a hot water 
bag until the pain ceases. 

If the pain continues more than twelve hours, it is advisable to 
consult an aurist who will lance the drum of the ear if an abscess 
is forming — rather than to wait until it breaks open spontaneously 
— to avoid complications. 

The ear drum is not essential to hearing, but is valuable in keep- 
ing out dust, water, germs, etc., which are likely to set up inflamma- 
tion of the middle ear. The opening in the drums, caused by the 
escape of "matter," usually closes, but even if it does not, deafness 
may not follow. If the contents of an abscess in the middle ear are 
not allowed to escape as soon as possible there is danger of an abscess 
in the mastoid cells in the bone of the skull back of the ear — a much 
more serious disease. Then after the abscess begins to discharge 
from the ear, if the condition is neglected, a chronic discharge lasting 
for months or years may ensue. This again threatens the patient 
in leading to destruction of the bones of the ear, to deafness, mastoid 
abscess, and various complications. 

When the ear begins to run after an earache, the discharge is 
a sign that fluid has formed and broken through the ear drum. The 
ear should be wiped dry twice daily with clean absorbent cotton 

1 Laudanum and paregoric can only be obtained with a doctor's prescription. 



DISEASES OF THE EAR 711 

wrapped on a toothpick. Then it should be wiped in the same way 
with cotton wet with a solution of hydrogen peroxid, dried with 
cotton, and some boric acid powder should be dusted in the ear from 
a salt shaker. 

Gentle syringing with a saturated solution of boric acid in a foun- 
tain syringe may be used, if there is a great amount of discharge, and 
the ear may be then dried, as described above, and dusted with pure 
boric acid. If at any time, with abscess of the ear, pain begins back 
of the ear, mastoid inflammation may be suspected. This is often 
seen with sudden cessation of the discharge from the ear. 

Moderate of Slight Earache 

A slight or moderate earache, which may, however, be very per- 
sistent, though not sufficient to incapacitate the patient or prevent 
sleep, is often caused by some obstruction in the eustachian tube, 
either by swelling or mucous discharges (in adenoid growths, en- 
larged tonsils, chronic catarrh, etc.). 

This condition gives rise to the train of effects noted in the sec- 
tion on deafness. The air in the middle ear is absorbed to some 
extent, and therefore the pressure within the ear is less than that 
outside the drum, so that the latter is pressed inward, with the re- 
sult that pain, and perhaps noises and deafness ensue, and if the 
condition is not relieved, inflammation of the middle ear as described 
above. 

Treatment. — Treatment should be directed toward cleaning the 
back of the nose and reducing swelling at the openings of the eusta- 
chian tubes in this locality, and inflating the tubes with air. A 
coarse, warm spray of Seiler's solution should be thrown from an 
atomizer through the nostrils, with the head tipped backward, until 
it is felt in the back of the throat ; after the water has drained away 
the process is to be repeated a number of times. This treatment 
should be pursued twice daily. 

One hour after the fluid in the nose is well cleared away the 
eustachian tubes may be inflated by the patient. To accomplish this 
the lips should be closed tightly, and the nostrils also, by holding 
the nose; then an effort must be made to blow the cheeks out until 



712 THE EYE AND EAR 

air is forced into the tubes and is felt entering both ears. This 
act is attended with danger of carrying fluid up into the tubes and 
greatly aggravating the condition, unless the water from the spray 
has had time to drain away. 

Blowing the nose, as has oeen pointed out, is unwise, but the 
water may be removed to some extent by "clearing the throat." The 
reduction of swelling at the entrance of! the eustachian tube in the 
back of the nose can be properly treated only by an expert, as some 
astringent (glycerite of tannin) must be applied on cotton wound 
on a curved applicator, and the instrument passed above and behind 
the roof of the mouth into the region back of the nose. The specialist 
also has improved methods of inflating the eustachian tubes. 

Rubbing the parts just in front of the external opening into the 
ear with the tip of one finger, for a period of a few minutes several 
times a day, will also favor recovery in this trouble. 

MASTOID INFIiAMMATION 

Causes. — This may be induced by forcible syringing of the ear 
in driving germs through the hole in the drum (after ear abscess) 
back into the middle ear and thus into the mastoid cells, which con- 
nect with the middle ear. 

However, mastoid inflammation may occur with the best of care 
and often arises in the first or second week of ear abscess or later 
in chronic cases. 

Symptoms. — There is severe pain about the ear, back of the ear 
and over the whole side of the head, with tenderness on pressure over 
the bone just behind the external opening in the ear. Eever is usu- 
ally also present. Local redness and swelling may also occur over 
the mastoid region. 

If the tenderness of the bone behind the ear and pain do not sub- 
side within twenty-four hours surgical assistance must be obtained 
at any cost, as a fatal result may ensue. 

Treatment. — Rest in bed and the application of heat by' the 
means of hot water over the mastoid region is the best way of treat- 
ing the patient until the aid of an ear specialist or physician is se- 
cured. 



DISEASES OF THE EAR 713 

An icebag is also frequently used for this purpose and may re- 
lieve the pain and inflammation more satisfactorily than dry heat; 
heat is, however, more commonly to be preferred. 

While inflammation of the mastoid often subsides in the course 
of an ear abscess without operation, still, in case of doubt, operation 
is advisable because in early cases it is without danger, and because 
of the great fatality of such complications as abscess of the brain, 
meningitis, etc., in neglected mastoid abscess. 



CHAPTER XIII 

BURNS AND FROSTBITE 

Burns and scalds. Frostbite. Chilblains and mild frostbite. Treatment of 
general effects of cold. 

BURNS AND SCALDS 

A burn is produced by dry beat; a scald by moist heat. The 
effect and treatment of both are practically identical. Burns are' 
commonly divided into three classes, according to the amount of 
damage inflicted upon the body. 

First Class. — There is redness, pain, and some swelling of the 
skin followed, in a few days, by peeling of the surface layer (epi- 
dermis) and recovery. Sunburn and burns caused by slight expos- 
ures to gases and vapors are included in this class. 

Treatment. — The immediate immersion of the part in cold water 
is followed by relief, or the application of cloths wet with a saturated 
solution of saleratus or baking powder is useful. Anything whfbh 
protects the burned skin from the irritating effect of the air is effica- 
cious, and in emergencies any one of the following may be applied : 
starch, flour, molasses, white paint, or a mixture of white of egg and 
sweet oil (equal parts). Usually after the first pain has been re- 
lieved by bathing with soda and water, or its application on cloths. 
the employment of a simple ointment, such as cold cream or vaselin, 
suffices. 

Second Class. — In this class of cases the inflammation is more 
severe and the deeper layers of the skin are involved. In addition 
to the redness and swelling of the skin there are present blisters 
which appear at once or within a few hours. The general condition 
is affected according to the size of the burn. If half of the body is 
reddened, death usually results, and a burn of a third of the body 
is often fatal. 

714 



BURNS AND SCALDS 715 

The shock is so great at times that pain may not be at once in- 
tense. Shock is evidenced by general depression, with weakness, 
apathy, cold feet and hands, and failure of the pulse. If the patient 
rallies from this condition, then fever and pain become prominent. 

If steam has been inhaled, there may be sudden death from 
swelling of the interior of the throat, or inflammation of the lungs 
may follow inhalation of smoke and hot air. 

Third Class. — In this class are included burns of so severe a 
nature that destruction and death of the tissues follows ; not only of 
the skin but, in the worst cases, of the flesh and bones. It is impos- 
sible to tell by the appearance of the skin what the extent of the 
destruction may be until the dead parts slough away after a week 
or ten days. The skin is of a uniform white color in some cases, or 
may be of a yellow, brown, gray, or black hue, and is comparatively 
insensitive at first. 

Pus ("matter") begins to form around the dead part in a few 
days, and the dead tissue comes away later, to be followed by a long 
course of suppuration, pain, excessive granulations ("proud flesh"), 
and unless skillfully treated, by contraction of the surrounding area, 
leaving ugly scars and interfering with the appearance and useful- 
ness of the parts. The treatment of such cases after the first care 
becomes that to be pursued in wounds generally (page 18), and 
belongs within the domain of the surgeon. 

Treatment of the More Severe Burns. — If the patient is suffer- 
ing from shock he should receive some hot alcoholic drink, as hot 
water and whisky, and be put to bed under warm coverings with 
hot-water bags or bottles at his feet. 

The clothing must be cut away from the burned parts with the 
greatest care, and only a portion of the body should be uncovered at 
a time. This should be done in a warm room. i 

Pain may be subdued by laudanum 1 ; fifteen drops may be given 
to an adult, and the drug may be repeated at hour intervals in doses 
of ten drops until the suffering has been allayed. Lumps of ice held 
in the mouth will quench the thirst, and the diet should be liquid — 
milk, soups, gruels, white of egg, and water. The bowels should be 

*Can be obtained only with doctor's prescription. 



716 BUEXS AND FROSTBITE 

moved daily by rectal injections of soap and warm water. As a 
matter of local treatment, the surface layer of the skin should be 
kept intact if possible. Blisters are not to be disturbed unless they 
are large and tense ; if so, their bases may be pricked with a needle 
to let out the fluid contents. 

Carron oil (equal parts of olive oil and lime water) has been the 
common remedy for burns, and it is an efficient, though very dirty 
dressing, useful if the skin is generally unbroken. It should be 
applied on clean soft linen or cotton cloth, which is soaked in the 
oil, laid over the burned area and covered with a thick layer of 
cotton batting and a bandage. When the skin is denuded, leaving a 
raw surface exposed, the burn must be treated on the same plan as 
wounds, and should be kept as clean and free from germs as possible. 
An ointment made of equal parts of boric acid and vaselin, spread 
thickly on a sterile cloth, is a good antiseptic preparation in cases 
where the skin is broken. Oil silk or gutta percha tissue is prefer- 
able to sterile gauze or cloth, as they do not stick to the raw tissues. 

It is best not to change the dressing oftener than once in two or 
three days, unless the discharge or odor is considerable. Fresh 
dressing is very painful and often harmful. 

When the dressing is removed, warm saline solution (one tea- 
spoonful of common salt in one quart of water ) is allowed to flow 
over the burn until all discharge is washed off. Then the raw sur- 
face is dusted over with pure boric acid or aristol. and the boric-acid 
ointment applied as before. The cloth upon which the ointment is 
spread should be made free from germs by boiling in water, and 
then drying in an oven and keeping it well wrapped in a clean towel 
until used. 

The same care is requisite as that described under Wounds (page 
18) in regard to cleanliness. 

Very extensive burns are treated most satisfactorily without any 
dressings whatever. The pain of removing surgical dressings, and 
the irritation of the raw surface occasioned thereby, are thus avoided 
— a tremendous gain, especially in children. 

The patient, wholly nude, should be placed in a kind of tent on 
a clean sheet. Electric lights are often used within the tent to bring 



FROSTBITE 717 

the temperature to more nearly that of the body. The raw surfaces 
of the burns should be protected by frequent dusting with pure 
powdered boric acid. 

The open air treatment of burns is said to have been adopted 
from the American Indians and, in the case of children particularly, 
one avoids the piteous and heartrending cries and pain attending 
the older methods of dressing burns, and at the same time it is most 
favorable to healing. 

It is beyond the scope of this work to describe the various com- 
plications and the details of the after-treatment in severe burns — 
including skin grafting — which may tax the ingenuity of the skilled 
surgeon. It is hoped that the foregoing may give a clear idea of the 
treatment to be pursued in emergencies and may prove of some use 
to those who may unfortunately be compelled to care for burns dur- 
ing a considerable time without the aid of a physician. 

Burns Caused by Strong Mineral Acids or by Alkalis. — If acids 
are the cause, the skin should not be washed at first, but either chalk, 
whiting, or some mild alkali, such as baking soda, should be strewn 
over the burn. After the effect of the acid is neutralized, the soda 
should be washed off with a stream of warm water. Dry gently with 
gauze. Apply Carron oil or paste of boric acid and vaselin, equal 
parts. If strong alkalis have been spilled on the skin, as ammonia, 
potash, or quicklime, then vinegar is the proper substance to employ, 
followed by washing and gentle drying. Yaselin or cold cream is 
usually sufficient as after-treatment. Lime water is useful in coun- . 
teracting the effect of acids spattered in the eye. In the case of 
alkalis in the eye, the vinegar used should be diluted with three 
parts of water. Albolene or liquid vaselin is the best agent to drop 
in the eye after an accident, in order to relieve the irritation and 
pain; in addition, the patient should stay in a dark room. 



FROSTBITE 

The nose, chin, ears, fingers, and toes are the parts usually 
frozen, although severe results ending in death of the frozen part 



718 BURNS AND FEOSTBITE 

are more often due to the low vitality of the patient than to the cold 
itself. In the milder degree of frostbite there is stiffness, numbness, 
and tingling of the frozen member ; the skin is of a pale, bluish hue 
and somewhat shrunken. Recovery ensues with burning pain, ting- 
ling, redness, swelling and peeling of the epidermis, as after slight 
burns. The skin is icy cold, white, and insensitive in severe forms 
of frostbite and, if not skillfully treated, later becomes either swollen 
and discolored or shriveled, dry and black. 

In either case the frozen part dies and is separated from the liv- 
ing tissue after the establishment of a sharp line of inflammation 
which results in ulceration and formation of pus, and thus the dead 
parts slough off. It is, however, possible for a part thoroughly frozen 
to regain its vitality. 

Treatment. — The essential element in the treatment is to secure 
a very gradual return of blood to the frozen tissues, and so avoid 
violent inflammation. To obtain this result the patient should be 
cared for in a cold room, the frozen parts rubbed gently with snow, 
or cloth wet with ice water, until they resume their usual warmth. 
Then it is well to rub them with a mixture of alcohol and water 
(equal parts) for a time and expose them to the usual temperature 
of a dwelling room. Warm drinks should not be administered to 
the patient. 

The frozen member, if hand or foot, should be raised high in the 
air on pillows and covered well with absorbent cotton and bandage. 
If much redness, swelling, and pain result this dressing should be 
removed and the part wrapped in a single thickness of cotton cloth 
kept continually wet with alcohol and water. 

Subsequent treatment consists in keeping the damaged parts cov- 
ered with vaselin or cold cream, absorbent cotton, and bandage. If 
blisters and sores result, the care is similar to that described for like 
conditions, under Burns. If death of the frozen part becomes inevi- 
table, the hand or foot should be suspended in a nearly vertical posi- 
tion to keep the blood out, and the part bathed twice daily with a 
solution of corrosive sublimate (one 7.7 grain tablet to one pint of 
water), dusted well with aristol, and dressed with absorbent cotton 
and bandage until the dead tissue separates and comes away. If the 



CHILBLAINS AND MILD FROSTBITE 719 

frozen part is large it may be necessary to remove it with a knife; 
but this is not essential when the tips of the fingers or toes are frozen. 



CHILBLAINS AND MILD FROSTBITE 

The effects of severe cold on the body are very similar to those of 
intense heat, though they are very much slower in making their 
appearance. After a person has a frozen finger or toe he may not 
notice much inconvenience for days, when suddenly violent inflam- 
mation may set in. The fingers, ears, nose, and toes are the mem- 
bers which suffer most frequently from the effects of cold. Similar 
symptoms of inflammation, described under Burns, also result from 
cold — that is, redness and swelling of the skin, blisters with more 
severe and deeper inflammatory involvenlent, or, in case the parts 
are thoroughly frozen, local death and destruction of tissues. 

But it is not essential that the body be exposed to the freezing 
temperature or be frozen at all, in order that some harm may result, 
for chilblains often follow when the temperature has not been lower 
than 40° F. or thereabouts. 

The effect of cold is to contract the blood vessels, with the pro- 
duction of numbness, pallor, and tingling of the skin. When the 
cold no longer acts, the blood vessels dilate to more than their usual 
and normal state, and more or less inflammation results. The more 
sudden the return to warmth the greater the inflammatory sequel. 

Chilblains represent the mildest morbid effect of cold on the 
body. They exist as bluish-red swellings of the skin, usually on the 
feet or hands, but may attack the nose or ears, and are attended by 
burning, itching, and smarting. This condition is caused by dilata- 
tion of the vessels following exposure to cold. It is more apt to 
happen in young, anemic women. Chilblains usually disappear dur- 
ing warm weather. Scratching, friction, or the severity of the attack 
may lead to the appearance of blisters and sores. In severe cases 
the fingers and toes present a sausage-like appearance, owing to 
swelling. 

Treatment. — Susceptible persons should wear thick, warm (not 



720 BURNS AND FROSTBITE 

rough) stockings and warm gloves. The chilled members must never 
be suddenly warmed. Regular exercise and cold shower baths are 
good to strengthen the circulation, but the feet and hands must be 
washed in warm water only, and thoroughly dried. 

If sweating of these parts is a common occurrence, starch or zinc 
oxid should be dusted on freely night and morning. Cod-liver oil 
is an efficacious remedy in these cases — one teaspoonful of Peter 
Moller's pure oil three times daily after meals. The affected parts 
should be bathed twice daily in a solution of zinc acetate (one drachm 
to one pint of water), and followed by the application, on soft linen 
or cotton, of zinc-oxid ointment containing two per cent, of carbolic 
acid. If this is not curative, iodin ointment mixed with an equal 
quantity of lard may be tried. Exposure to cold will immediately 
bring on a recurrence of the trouble. If the affection of the feet is 
severe the patient must rest in bed. If the parts become blistered 
and open sores appear, then the same treatment as for burns is indi- 
cated. Wash with a weak solution of corrosive sublimate (one T 1 ^ 
grain tablet for surgical purposes in two quarts of warm water) and 
apply an ointment of boric acid and vaselin, equal parts, spread on 
soft, clean cotton or linen. Rest of the part and existence in a warm 
atmosphere will complete the cure. 



TREATMENT OF GENERAL EFFECTS OF COLD 

Sudden exposure to severe cold causes sleep, stupor, and death. 
Persons found apparently frozen to death should be brought into a 
cold room, which should be gradually heated, and the body rubbed 
with snow or ice water, and artificial respiration employed (See page 
42). 

Attempts at resuscitation ought to be persistent, as recoveries 
have been reported after several hours of unconsciousness and ap- 
parent death from freezing. 



CHAPTEE XIV 
THE MEDICINE CHEST 



NECESSARY DRUGS AND DOSES OF DRUGS FOR ADULTS 

AND CHILDREN 

Besides the necessary drugs, the medicine chest or closet should 
contain measuring glasses. It should also be arranged for dispensing 
medicines quickly and conveniently. 

The two most important articles are : a glass graduate measuring 
up to two ounces, and a minim graduate, measuring drops. The lat- 
ter is useful in the case of powerful medicines. Drops vary in size 
according to the utensil from which the fluid is dropped, or the char- 
acter of the liquid. All medicine in fluid form should be measured 
in a drop or minim graduate. 

Dry tablets are the easiest form of medicine to dispense; many 
drugs, however, are inert when dried and compressed — such, for in- 
stance, as many of the tinctures. 

A teaspoon of the old style holds approximately one drachm, or 
sixty minims (modern teaspoons often hold a quarter of a drachm 
more) and a tablespoonful about one-half an ounce. A sherry wine- 
glass holds about two ounces, and a glass tumbler holds about one- 
half a pint. 

The chest should contain a small pair of scales with brass weights, 
measuring from one-half a grain to two drachms. 

The medicine chest should not be kept locked; valuable time 
might be lost in searching for the key, when prompt aid is neces- 
sary. It should, however, be kept out of the reach of children. 

The following drugs, etc., should be included in the contents : 

721 



722 



THE MEDICIXE CHEST 



Aconite, tincture of 
Alcohol (for external use) 
Aromatic spirit of ammonia 
Aromatic fluid extract caseara 

sagrada 
Aspirin, 10 grain tablets 
Boracic (or boric) acid 
Bromid of sodium 
Blaud's pills of iron 
Bismuth subnitrate 
Calomel tablets, ^4 grain 
Castor oil 
Chalk mixture 
Chloroform liniment 
Cholera mixture 
Compound cathartic pills 
Corrosive sublimate tablets 
DobelFs solution 
Dover's powder 

Elixir of heroin and terpin hydrate 
Ether 
Glycerin 

Iodin, tincture of 
Ipecac, syrup of 



Limewater 

Magnesia citrate 

Magnesia sulphate (Epsom salt) 

Morphin tablets (*4 grain) 1 

Mustard leaves 

Niter, sweet spirit of 

Phenacetin tablets 

Paregoric * 

Quinin capsules (3 grains) 

Soda, bicarbonate of 

Vaselin 

Veronal tablets (5 grains) 

Whisky 

Atomizer 

Catheters (soft rubber) 

Clinical thermometer 

Corks; rubber stoppers 

Corkscrew 

Cup 

Fountain syringe 

Labels 

Spoons 

Stomach tube 



The poisons in this list should be kept in rough, blue bottles, 
labeled "poison," and include the tincture of aconite and iodin, 
chloroform liniment, morphin, and corrosive sublimate tablets. 
Where there are children about it is safer to keep these drugs under 
lock and key. The morphin tablets are not necessary unless one is 
far away from medical aid. 

The doses given in the following table are for adults. Frac- 
tional doses, suitable for those under adult age, are as follows : 

For 16 years 3/4 the adult dose 

For 12 years 1/2 " " 

For 8 to 10 years 2/5 " 

For 6 years 1/3 " « 

For 3 years 1/5 " " 

For 2 years 1/7 " " 

i Morphin and paregoric can be obtained only on a doctor's prescription. 



NECESSARY DRUGS AND DOSAGE 723 

For 1 year 1/10 the adult dose 

For 9 months 1/15 " 

For 6 months 1/20 " 

From birth to 3 months 1/30 " 

In the following table, the drugs which are marked with a star 
are powerful, and may cause poisoning if given in a large dose 
or if repeated frequently, or oftener than once in a few hours. Many 
of these drugs may be bought in tablet form. 

A minim is a measured drop. A drachm consists of 60 grains or 
60 minims. 

Doses for Adults 

Arsenic * 1/30 grain 

Arsenic, Fowler's solution of * 3 minims 

Aconite, tincture of * 10 minims 

Alum, as emetic 30 to 60 grains 

Ammonia, aromatic spirit of y 2 to 1 teaspoonf ul 

Ammonia, solution of acetate of 1 teaspoonf ul 

'Ammonium chlorid 4 grains 

Amyl nitrite, by inhalation 5 minims 

Apomorphin (emetic) * 1/10 grain 

Aspirin 10 grains 

Atropin sulphate * 1/100 grain 

Belladonna, solid extract of * .... ; *4 grain 

Belladonna, tincture of * 5 to 8 minims 

Bismuth subcarbonate 20 grains 

Bismuth subnitrate 20 grains 

Boric acid 5 to 10 grains 

Bromoform * 5 to 10 minims 

Calomel Vs grain, repeated doses ; 

3 to 5 grains as a sin- 
gle dose 

Camphor 2 grains 

Camphor, spirit of 15 minims 

Capsicum (red pepper) 1 grain 

Capsicum, tincture of 3 minims 

Cascara sagrada, fluid extract of 15 to 30 minims 

Castor oil ' Adult, 3 to 4 tablespoon- 

fuls; child, 1 to 2 tea- 
spoonfuls 
Cerium oxalate 3 grains" 



724 THE MEDICINE CHEST 

Chalk, prepared 15 to 30 grains 

Chalk, mixture 1 to 2 oun : e ; 

Chloral * 10 to 15 grains 

Chloroform * 5 minims 

Chloroform, spirit of io to 1 drachm 

Cinchona, compound tincture of 1 drachm 

Codein * i 2 grain 

Colchicum, tincture of * 30 minims 

Colchicum, wine of * 30 minims 

Digitalis, tincture of * 15 minims 

Dover's powder (opium and ipecac) * 10 grains 

Ergot, fluid extract of 1 drachm 

Ether * 15 minims 

Ether, nitrous, spirit of i 2 drachm 

Gentian, tincture of 1 drachm 

Ginger, fluid extract of 1 U !( minims 

Hamamelis fluidextraet (witch-hazel I 1 drachm 

Hyoscin hydrobromate * 1 100 grain 

Hypophosphites, compound, syrup of 1 drachm 

Ipecac, syrup of y 2 t0 1 drachm 

Ipecac, wine of 1 2 to 1 drachm 

Ipecac, wine or syrup, as emetic 3 to 6 drachms i adult ) 

Ipecac, powdered, as emetic 30 grains 

Iron (Blaud's pills), subcarbonate of 5 grains 

Iron, syrup of iodid of 15 niinims 

Iron and quinin citrate 10 grains 

1 Laudanum (See opium, tincture of ) 8 minims 

Limewater 4 drachms 

Lithium citrate 5 grains 

Magnesia 1? grains 

Magnesium citrate, solution of 6 ounces ( 1 gb 

Magnesium sulphate ( Epsom salt ) 4 drachms 

Male fern.* oleoresin of V 2 drachm 

Malt, extract of 1 to 2 drachms 

Mercury, blue pills 3 to 10 grains 

1 Morphin * and its salts 1/8 to 1 3 grain 

Nux vomica.* tincture of 10 niinims 

1 Opium,* extract of 1/8 to 1/3 grain 

1 Opium, tincture of (laudanum) S minims 

1 Opium, camphorated tincture of (paregoric) . 1 to 4 drachms 

Pancreatin 10 grains 

1 Caution. Dangerous. Use only on physician's prescription. 



NECESSARY DRUGS AND DOSAGE 725 

1 Paregoric * 1 to 4 drachms 

Peppermint, oil of 2 to 5 minims 

Peppermint, essence or spirit of y 2 to 1 drachm 

Pepsin and saccharated pepsin 15 grains to 1 drachm 

Phenacetin * ?% grains 

Potassium, bromid of 10 to 30 grains 

Potassium, citrate of 15 to 60 grains 

Potassium, iodid of 5 to 10 grains 

Quinin sulphate or tannate 2 to 20 grains 

Rhubarb, aromatic syrup of 1 to 4 drachms 

Rhubarb, tincture of y 2 to 1 drachm 

Salol and salophen 5 to 10 grains 

Salts, Epsom 1 even tablespoonful 

Salts, Rochelle 1 heaped teaspoonful 

Salts, Glauber's 1 even tablespoonful 

Santonin * 1 grain 

Senna, syrup of 1 to 4 drachms 

Silver, nitrate of Vi to y 2 grain 

Sodium bicarbonate (baking soda) 10 to 30 grains 

Sodium, bromid of 10 to 30 grains 

Sodium, salicylate of 10 to 20 grains 

Sodium sulphate, Glauber's salts 4 drachms 

Squill, compound syrup of 10 to 30 minims 

Squill, syrup of y 2 to 1 drachm 

Sulphur 1 drachm 

Sweet spirit of niter y 2 drachm 

Turpentine, oil of 15 minims 

Valerian, ammoniated tincture of y 2 to 2 drachms 

Zinc sulphate (emetic) 10 to 30 grains 

Doses of Drugs for Babies One Year Old 
(In the table the drugs which are marked with a star are pow- 
erful and dangerous in large or in repeated doses.) 

Aconite,* tincture of 1/3 to 1/2 minim 

Belladonna,* tincture of y 2 to 1 minim 

Bismuth, subnitrate of 5 grains 

Brandy 5 to 20 drops 

Bromid of potassium or sodium y 2 to 4 grains 

Calomel 1/10 grain Every 30 minutes or y 2 

grain in single dose 
1 Caution: Dangerous. Use only on physician's prescription. 



726 THE MEDICINE CHEST 

Castor oil 1 drachm 

Chloral * y 2 to 1 grain 

Citrate of potash 1 to 2 grains 

Cod-liver oil x /4 to V2 drachm 

1 Dover's powder % to y 2 grain 

Gin 10 to 15 drops 

Ipecac, syrup or wine of 1 to 2 minims 

Magnesia 5 to 20 grains 

Magnesia, citrate, solution of 6 to 8 drachms 

Xiter, sweet spirit of .2 to 4 minims 

1 Paregoric 3 to 10 minims 

Peppermint water y 2 to 1 drachm 

Ehubarb, spiced syrup of 1 drachm 

Senna, syrup of 10 to 15 minims 

Soda bicarbonate 1 to 2 grains 

Squill, compound syrup of ("hive syrup") .... 1 to 2 minims 

Squill, syrup of 2 to 5 minims 

Whisky r 5 to 20 minims 

Wine, sherry and port y 2 teaspoonf ul 

Table Showing Doses foe Children at Specified Ages 

6 months 18 months 3 years 5 years 

Aspirin ' 1 1-2 2-3 3-5 grains 

Belladonna, tincture y 2 1 1-2 3-5 drops 

Bismuth 10 10 10 20 grains 

Brandy 5-10 10-20 20-30 30-40 drops 

Bromid, sodium or 

potassium 2 3 4 6 grains 

Calomel 1/10 1/6 grain every 30 min. s 

Calomel % y± grain every hour 

Camphor, spirit of. 3 5 5-10 10 drops 
Cascara sagrada, aro- 
matic fluidextract 

of 15 30 30 60 drops 

Castor oil 1 2 3 4 teaspoonf uls 

Chloral 2 3 5 10 grains by the rectum 

Ipecac syrup or 

wine 1 1-2 3 3-5 drops 

x Paregoric 3-5 10 15-20 20-30 drops 

1 Can be obtained only with doctor's prescription. 

2 It will rarely be necessary to give more than a grain of calomel including 
all the doses given. 



FIRST AID SURGICAL OUTFIT 727 

Quinin sulphate ... % 1-2 2-3 3-4 grains 

Quinin tannate in 

chocolate tablets. 1 2-4 4-6 6-8 grains (Best form 

for children) 

Whisky 5-10 10-20 20-30 30-40 drops 



FIRST AID SURGICAL OUTFIT 

A first aid surgical outfit is desirable for use in mills, logging 
camps, military camps, mines, vessels, wherever numbers of persons 
are employed, and for those living in remote places. The following 
outfit includes the essentials. The quantity of materials may be 
altered to suit the circumstances : 

1 dozen sterile gauze bandages, 2% inches wide. 

1 roll of zinc oxid plaster, 3 inches wide, 10 yards long. May be 

torn any width. 
1 dozen packages each containing 1 yard of sterile gauze. 

1 pound of absorbent cotton. 

2 packages each containing 1 square of oil silk about 1 foot 

square. 
1 pair of straight surgical scissors with blunt points (Mayo). 
1 pair of dissecting forceps. 

1 pair of small needle forceps. 

6 glass tubes, each containing needles threaded with surgical silk 
(sterile). 

6 glass tubes each containing No. 1 iodized catgut sutures steril- 
ized. 

2 enamel hand basins. 
1 hand scrub brush. 

6 curved medium-sized surgical needles with cutting edge. 

4 ounces of tincture of iodin. 

1 bottle of large size tablets of corrosive sublimate. 

4 collapsible metal tubes of borated vaselin. 



728 



THE MEDICINE CHEST 



Boric acid in tin, % pound. 
Collodion, 2 ounces. 

1 glass syringe holding 2 ounces. 

2 ounces of compound tincture of ben- 

zoin. 

1 quart of denatured alcohol. 

8 ounces of compound cresol solution. 
8 ounces of hydrogen dioxid. 

2 ounces of Peruvian balsam. 
6 ounces of whisky. 

1 tourniquet. 



These should be kept in a 
suitable cupboard or chest. 
When only a small outfit is re- 
quired the iodin, gauze and 
bandages should be selected and 
the rest rejected. The corrosive 
sublimate tablets and Peruvian 
^-balsam are most useful for 
daily dressing of wounds. The 
instruments most essential are 
scissors and forceps. 

All the rest of the outfit may 
be dispensed with when only a 
small outfit can be used, on ac- 
count of weight or expense. 



INDEX 



INDEX 



Abdominal pain, 530 

causes of, 532 

treatment of, 530 
Abortion, 211-212 
Abrasion, 34 
Abscess, alveolar, 434 

of ear, 708 
Acetanilid, 175 
Acetic acid, 176 
Acids, burns by, 176 

poisoning by, 176 
Acne, causes of, 150 

treatment of, 150 
Aconite, 176 
Adenoids, 437 

Age, degenerative changes in, 490 
Ague cake, 450 
Albumin water, 256 
Alcohol, actions of, 292-293 

uses of, 295 
Alcoholic drinks, 294 

composition of, 294 
Alcoholism, 647 
Alkalis, burns by, 176 

poisoning by, 176 
Alveolar abscess, 434 
Amenorrhea, 200 

treatment of, 202 
Ammonia, 176 
Anemia, causes of, 487-488 

symptoms of, 489 

treatment of, 489 
Ankle, broken, 79 

fracture of, 70 

sprain of, 28 
Antidotes, 174 
Antimony, 177 
Antipyrin, 175 

Antitoxin, diphtheria, 447-451 
Apoplexy. See Unconsciousness. 
Appendicitis, acute, 532 

causes of, 532 



Appendicitis, chronic, 516 

symptoms of, 532 

treatment of, 534 
Arm, broken, 66 

fractured, 66 
Arsenic, 177 
Arteries, bleeding from, 3 

hardening of, 490 
Arteriosclerosis, 490 

causes of, 491 

symptoms of, 492 

treatment of, 492 
Arthritis, 603, 608 
Artificial respiration, 37-44 

Howard's method, 42 

Sylvester's method, 37 
Asiatic cholera, 556 
Asthma, causes of, 475 

symptoms of, 475 

treatment of, 476 
Astigmatism, 697 
Athletics, home, 307 
Atony, stomach, 525 
A tropin, 177 

Baby, bad habits of, 238 

bedwetting, 239 

masturbation, 238 

sleeplessness, 238 

thumb sucking, 239 
bathing of, 233 
bowel discharges of, 236 
care of, after birth, 232 
clothing of, 234 
diet for, 239 

food for first month, 244 

food for first seven months, 245 
immediate care of, at birth, 224 
learning to talk, 236 
learning to walk, 236 
nursing of, 238 
skin of, care of, 233 



731 






DsDEX 



Baby, teething of, 237 

temperature of room for, 234 
utensils for feeding, 248 
ventilation of room for, 234 
•wean in g of, 261 
weighing of, 235 
Baek, sprain of, 234 

rheumatism of, 606 
Baldness, treatment of, 158, 270 

varieties of, 158 
Bandages, forms of, 93 
"breast, 101 
cravat, 101 
eye, 102 

figure of eight, 98, 99 
foot, 97, 100 
for eye, 102 
head, 101 
jaw, 63, 100 
limb, 95, 99 
neck, 96 
shoulder, 96 
spica, 96 

of ankle and foot, 97 

of shoulder, 96 
spiral reverse, 95, 99 
T-bandage, 95 
thigh, 100 
triangular, 100 

of breast, 101 

of eye, 101 

of foot, 100 

of head, 101 

of jaw, 102 

of shoulder, 101 

of thigh, 100 
Barley gruel, 254 
Barley water, 253, "". 
Bathing, in convulsions, 638 
indoor, 265 
in malaria, 412 
in pneumonia, 463 
in scarlet fever, 356 
in skin irritations, 145 
in smallpox, 376 
in typhoid fever, 395 
in yellow fever, 418 
outdoor, 266 
Baths, eold, 265 
hot, 268 



Baths, outdoor, 266 
tepid, 268 
Russian, 268 
Turkish, 268 
warm, 268 
Bed bngs, 171 
Bed sores, eare of, 397 
Bedwetting, 239 
Bee stings, 168 
Beef, Bcraped, 257 
Beef broth, 258 
Beef juiee, 254 
Beef tea, 258 
Belladonna, 177 
Beriberi, 589 
causes of, 589 
prevention of, 592 
symptoms of, 592 
treatment of, 592 
Bilious fever, 406 
Biliousness, 507, 561 
Bites, of insects, 167 
bed bugs, 171 
bees. 168 
centipedes lf3 
dog, 143 
flea, 171 

hornet, 168 
liee, clothes, 170 
crab, 170 
head, 169 
moBquito. 167 
snake, 1 1 5 
spider, 173 
tarantula. 173 
Trasp. 1 

wood tick, 166 
Black eye, treatment of, 686 
Blackhead, 149 
Black water fever, 410 
Bladder, inflammation of, 668 

stone in, 669 
Bleeding, after extraction of 
arrest cf . 

from arm and baad, 5 
from artery, 3 
from bowels, S 
from carotid artery, 14 
from face and neck, 4 



INDEX 



733 



Bleeding, from jugular vein, 5 

from lungs, 7 

from nose, 421 

from scalp, 4 

from shoulders and armpit, 5 

from stomach, 7, 495, 498, 512 

from thigh, foot and leg, 6 

from vein, 4 
varicose, 6 

from womb, 203 
Blepharitis, 689 
Blood, diseases of, 487 

oozing of, 2 

poor or anemic, 487 

vomiting of, 495, 498, 512 
Blue vitriol, 178 
Boils, 134 

causes of, 135 

treatment of, 135 
Bones, broken. See Fractures. 
Bowels, catarrh of, 546 

constipation of, 559 

inflammation of, 543 

normal passages of, 573 

obstruction of, 541 

prolapse of, 358 
Bow-legs, 348 
Brain, compression of, 52 

concussion of, 51 
Brandy, 294 
Breasts, cancer of, 107 

care of, after childbirth, 229 

inflammation of, 229 
Breath, foul, 279, 432 

holding of, 340 
Breathing, artificial, 37, 42 

how to count, 321 

rate of, at different ages, 321 
Bright 's disease, acute, 650 

chronic, 652 
Broken bone, of arm, 66 

of ankle, 79 

of collar bone, 61 

of elbow, 68 

of finger, 71 

of foot, 79 

of forearm, 68 

of hand, 71 

of hip, 72 

of jaw, 63 



Broken bone, of kneepan, 76 

of leg, 77 

of nose, 64 

of rib, 59 

of shoulder blade, 65 

of thigh, 74 

of toe, 80 

of wrist, 70 

symptoms of, 59 
Bronchial tubes, disease of, 458-462 
Bronchitis, symptoms of, 459 

treatment of, 460 
Broth, beef, 255, 572 

chicken, 255, 572 

clam, 260 

mutton, 255, 572 

oyster, 260 

veal, 255, 572 
Bruises, 32 

bandages for, 33 

of nails, 34 

of testicles, 34 

symptoms of, 32 

treatment of, 33 
Bunion, causes of, 125 

symptoms of, 125 

treatment of, 125 
Burns, about the eyes, 688 

first class, 714 

from acids, 176 

from alkalis, 176 

from electric shock, 41 

second class, 714 

severe, 714 

third class, 715 

Callus, of skin, 160 
symptoms of, 160 
treatment of, 160 
Camphor, 177 
Cancer, causes of, 105 

early operation in, 106 

general treatment of, 109 

of breast, 107 

of lip, 109 

of stomach, 109, 514 

of womb, 108 
Canker, 432 
Canned meats, 184 
Canned vegetables, 184 



734 



INDEX 



Cantharides, 177 
Car sickness, 498 
Carbohydrates, in food, 286 
Carbolic acid. 176 
uncle, 137 

treatment of. 13 S 
Catarrh, effect of, on ears, 704 

of bowels. 546 

of stomach. 347 
Catarrhal deafness. 704 
Catheter, use of. 324 
'. smstl: r : ta=h. 176 
Caustic soda, 176 
Centipede sting. 173 
Cereals, as food, 285-287 
C Ti::fied milk, 242 
Chafing, 147 

treatment of, 147 
gres fever, 407 
Champagne. 294 
Change of life, symptoms of, 212 

treatment of, 214 
Chs.pt mg. 147 

t:e;.tmert of. 147 
Cheese poisoning, 183 
Chickenpox, 377 

diagnosis of, : " 

period of development* 378 

symptoms of. •: " 5 

treatment of, 380 
Chilblains, 719 
Childbed fever. 231 
Chill'rjirtr.. 222 

after-pains in. 228 

articles needed during. _ '. 

bleeding after. 885-227 

care after, 226 

care during. 222 
Children, circumcision of, 329 

clothing for. 221, 234 

diet for. 261-264 

diseases of. 327. 565 
adenoids, 437 
bed-wetting. 239 

we", prolapse of, 330 
bowels, catarrh of ; 546 
bow-legs. 348 
breath, holding of. I 
breasts, inflammation or ." 
chickenpox. 377 



Children, diseases of, 

cholera infantum, 569 
chorea, 341 
colic, 252 

istipation, 573 
convulsions, 638 
cord, bleeding of, 329 
cough, 459 
ore-.:;. 4:5 

membranous, 452 
curvature of spine, 343-345 
diarrhea. 565 
diphtheria. 446 
dysentery, 567 
epile- r -1 
earache. 707-711 
fever, 333 
flat foot. : : 
glands, enlarged, 335 
growing pains, 332 
hip disease, 347 
holding the breath, 340 
knock-knees. 349 
larynx, spasm of. •: - ! 
lateral curvature, 345 
marasmus, 331 
masturbation, 676 
measles, 362 

German. 366 
milk r ::s:nir.g, 569 
mumps. 381 
phimosis. 328 
Pott "s disease, 343 
prolapse of bowel, 330 
retention of urine. : - 3 
rickets, 338 
ringworm. 153 
rupture, 117 
scarlatina, 356 
scarlet fever, 
scrofula. 335 
scurvy. 5 

sleeplessness, 238, 622 
sore mouth, 429 
sore navel 233 
St. Vitas 'a ;anee. 341 
teething. _ " 
tight foreskin. 128 
thumb-sucking. 239 
tuberculosis 171 



INDEX 



735 



Children, diseases of, 

urine, painful passage of, 327 
wasting, 331 
weak foot, 350 
whooping-cough, 383 
worms, 187 

food for, 216-264 

vaccination of, 373 
Chills and fever, 404 
Chloral, 177 
Chloroform, 178 
Chocolate, 291 
Cholera, Asiatic, 556 

true, 556 . 
Cholera infantum, 569 
Cholera morbus, 554 
Chorea, 341 
Cinder in eye, 685 
Circumcision, 329 
Clam broth, 260 
Clam poisoning, 182 
Claret, 294 
Climacteric, 212 
Clothing, proper, 271 

outer, 272 

underclothing, 271 
Cocain, 178 
Cocoa, 291 
Coddled egg, 255 
Coffee, 290 
Colchicum, 178 
Cold, exposure to, 423 

in the head, 423 
symptoms of, 425 
prevention of, 424 
sinus inflammation in, 425 
treatment of, 426 
Cold sore, 151 
Colic, gall-stone, 506 

in babies, 568 

intestinal, 530 

mucous, 539 

renal, 536 
Collar bone, broken, 61 

fractured, 61 
Collar bone fracture, 61 
Colles' fracture of wrist, 70 
Complexion, 269 
Compression of brain, 52 
Compound fracture of leg, 80 



Concussion of brain, 51 
Condensed milk, 260 
Confinement. See Childbirth. 
Congestion of eyelids, 689 
Conium, 178 
Conjunctivitis, 690 
Constipation, 

causation of, 559 

in adults, 559 

in children, 572 

in infants, 572 

symptoms of, 561 

treatment of, 561 
Consumption, causes of, 465-466 

fresh air in, 471 

outdoor life in, 471 

prevention of, 474 

symptoms of, 467 

treatment of, 470 
Contagion, in cholera, 556 

in conjunctivitis, 689 

in diphtheria, 456 

in eruptive fevers, 355-420 

in gonorrhea, 655 

in grippe, 479 

in mumps, 381 

in syphilis, 660 

in whooping-cough, 383 
Contagious diseases, 355 
Convulsions, in children, 57, 638 

in adults, 57, 638 

in unconsciousness, 57 
Cooking, 

baking, 277 

boiling, 277 

broiling, 277 

frying, 276-277 

of soups, 277 

roasting, 277 

sauteeing, 277 

stewing, 277 
Copper salts, 178 
Corns, 126 

Corrosive sublimate, 178 
Cough, acute and chronic, 458 

whooping, 383 
Crab poisoning, 182 
Cracks in skin or lips, 34, 160 
Creolin, 178 
Creosote, 178 



736 



INDEX 



Cross eye, 701 

Croup, membranous, 452 

symptoms of, 452 

treatment of, 452 
ordinary, 455 
spasmodic, 455 

symptoms of, 455 

treatment of, 456 
Curvature, of spine, 343 

angular, 343 

lateral, 345 
Custard, 260 
Cuts, treatment of, 2, 10, 12, 17 

small, 35 
Cystitis, 668 

Dandruff, 158, 270 

Dead child, in womb, 212 

Deafness, catarrhal, 704 

causes of, 705 

chronic, 704 

from wax, 702 

prevention of, 706 

sudden, 702 

symptoms of, 705 

temporary, 702 
Delirium tremens, 645 

symptoms of, 645 

treatment of, 646 
Deviation of nasal septum, 438 
Diabetes, 55, 575 

causes of, 575-577 

diet in, 578 

outlook, 578 

prevention of, 579 

symptoms of, 577 

treatment of, 579 
Diarrhea, acute, 546 

chronic, 546 

morning, 540 

of adults, 546 
symptoms, 547 
treatment, 548 

of children, 565 

summer, of infants, 567 
Diet, animal foods, 282-284 

beans, 285 

cereals, 285-287 

carbohydrates, 286 

eggs in, 284 



Diet, fat in, 286 

fish in, 282-283 

for aged, 283 

for babies, 239 

twelve to fifteen months, 261 

for children first to sixth year, 262- 
263 

for invalids, 253 

for long life, 283 

fruit, 288 

in diabetes, 579 

light and dark meat, 282 

meat in, 284 

milk, value of, 295 

obesity, 584 

proteids in, 281-284 

shellfish in, 283 

vegetable and animal, 288 
Digestion, diseases of, 505 

effect of dress on, 278 

hygiene of, 274 

process of, 275 
Digestive diseases, 505 
Digitalis, 179 
Diphtheria, 446 

causes of, 447 

diagnosis of, 446 

from milk, 447 

prevention of, 450 

symptoms of, 447 

time required for development, 447 

treatment of, 451 
Diseases, Bright 's, 650 

causing abdominal pain; 530 

children's, 327, 565 

diarrheal, 546 

digestive, 505 

genito-urinary, 655 

infectious, 355 

nervous, 613 

of air passages, 458 

of blood and blood vessels, 487, 490 

of ear, 702 

of gall-bladder, 506 

of heart, 483 

of lungs, 458-462 

of joints, 603 

of kidneys, 650 

of nose, 423 

of nutrition, 575 



INDEX 



737 



Diseases, of sexual organs, 655 

of skin, 145 
Dislocation, general treatment of, 84 

of elbow, 87 

of finger joints, 91 

of hip, 89 

of jaw, 84 

of shoulder, 85 

of thumb, 90 

symptoms of, 83 

treatment of, 4, 84 
Dog bites, 143 

mad, 143 
Doses of drugs, 723 
Dressings, for bruises, 33 

for wounds, 10 

surgical, 92 
Drinking, steady, 647 
Drinks, nutritious, 255, 572 
Drowned (apparently), 36 

artificial respiration in, 37 

restoring the, 36 

saving the, 36 
Drowning person, rescuing of, 38 

swimming to relief of, 38 
Drugs, doses of, 721-728 
Drunkenness, 50, 647 
Duodenum, ulcer of, 510 
Dysentery, in adults, 550 

in children, 567 
Dysmenorrhea, 199 
Dyspepsia, causes of, 510 

nervous, 512, 525, 527 

Ear, abscess of, 708 

diseases of, 702 

foreign bodies in, 706 

water in, 702, 708 

wax in, 702 
Earache, moderate, 707, 711 

severe, 708 

slight, 711 
Eczema, causes of, 161 

symptoms of, 162 

treatment of, 163 

varieties of, 162 
Egg, coddled, 255 
Egg nog, 260, 572 
Egg water, 256 
Egg white, 260 



Elbow, broken, 68 

dislocation of, 87 

fracture of, 68 

sprain of, 31 
Electric shock, 39 

symptoms of, 40 

treatment of, 41 
Enteric fever, 386 
Enteritis, catarrhal, 547 
Enterocolitis, 565 
Enteroptosis, 517 
Enuresis, 673 

Environment, importance of, 317 
Epilepsy, 54, 641 

causes of, 644 

diagnosis of, 641 

jacksonian, 644 

outlook in, 644 

spasms in, 641 

symptoms of, 641 

treatment of, 643 

without spasms, 642 

See also Unconsciousness. 
Eruptive diseases, 145 
Erysipelas, causes of, 165 

symptoms of, 165 

treatment of, 166 
Exercise, effect of, 302-304 

excessive, 305 

for all-round development, 305 

for boyhood, 306 

for children, 306 

for elderly men, 307 

for everyone, 307 

for middle-aged men, 307 

for youth, 306 

home, 307 

results of, 302-304 

without apparatus, 306 
Exhaustion, mental and nervous, 613 
Exophthalmic goiter, 112 
Eye, astigmatism of, 697 

black, 686 

catarrhal inflammation of, 689 

cinder in, 685 

cross, 70 

diseases of, 685 

far-sighted, 693 

foreign bodies in, 685 

hemorrhages into, 692 






INDEX 



Eye. hyperopic, 693 

lens of, 694 

muscles of, 700 
strain of, 699 

myopia, 693, 696 

near-sighted, 693, 696 

pink, 692 

retina of, 694 

sore, 689 

squint of, 701 

strain of, 693 

wounds and burns of, 688 
Eyelids, congestion of, 689 

inflammation of, 690 
edge of lids, 686 

stye on, 687 

twitching of, 688 
Eye muscles, weakness of the, 700 
Eye strain, 693 

symptoms of, 699 

treatment of, 701 
Extractives in food, 283 

Facial neuralgia, 637 
Facial paralysis, 633 
Fainting, 49 

See also Unconsciousness. 
Farsightedness, 693 
Fat, as food, 286 

reduction of, 552 
Fatigue, muscular, causes of, 303 
Feeding, of babies, 239 
troubles in, 239 
utensils in, 248 
Feet, sweating of, 272 
Felon, causes of, 130 

symptoms of, 130 

treatment of, 131 
Fetus, death of, 212 
Fever, bilious, 408 

black water, 410 

Chagres, 407 

chills and, 403 

enteric, 386 

eruptive, 356 

gastric, 3S6 

hay, 478 

in children, 333 

infectious. 356 

intermittent, 403 



Fever, remittent, 408 

rheumatic, 603 

scarlet, 356 

typhoid, 386 

yellow, 414 
Fever blister. 151 

See also Herpes. 
Fevers, eruptive, contagious, 356 
Finger, broken, 71 

dislocation of, 91 

fracture of, 71 

nails of, care of. 271 

sprain of, 30 
First aid in wounds. - 
First aid surgical outfit, "_" 
Fish r as foe: 28B-28S 
Fish poisoning, 182 
Fits, 57 
Flat foot, 350 
Flea bites. 171 
Flies, 172 

Flowing from womb 203 
Fly bites, 172 
Food, containing parasite. 1 8 : 

carbohydrates in. 28C 

constituents of. 281 

.comparative value of, _fl 

extractives in. _. 

fat in. 28C 

for babies. 253-262 
first month, 239-245 
first week. 239-245 

for the sick, i ' 

frying. 2 " 

infant. 253 

patent, for babies, 261 

proteids h 881-28 -: 

purins in. _ \ _ 
Food poisoning, 151 

symptoms of. 184 

treatment of, 185 
Foot, broken, 79 

fiat, 350 

fracture of, 79 

weak, 350 
Foot gear. _"_ 
Forearm fractu:- 
Foreign bodies, in the ear, 706 

in the eye, 6^5 

in the nose, -_* 



INDEX 



739 



Foreign bodies, in the throat, 428 
Foreskin, adhering, 328 

tight, 328 
Formalin poisoning, 179 
Foul breath, 279, 432 
Fourth-of-July accidents, 20 
Fowler 's Solution, 177 
Fracture, 58 

Colles , , 70 

compound, 58 
of leg, 80 

of ankle, 79 

of arm, 66 

of collar bone, 61 

of elbow, 62 

of finger, 71 

of forearm, 68 

of foot, 79 

of hand, 71 

of hip, 72 

of jaw, 63 

of kneepan, 76 

of leg, 77 

of nose, 64 

of rib, 59 

of shoulder blade, 65 

of skull 

See Unconsciousness. 

of thigh, 74 

of thumb, 72 

of toe, 80 

of wrist, 70 

simple, 58 

symptoms of, 59 
Freckles, treatment of, 154 
Freezing, 720 
Frostbite, 719 
Fruit, as diet, 288 
Frying, 276 

Gall-bladder, disease of, 506 

symptoms of, 506 

treatment of, 507 
Gall-stone colic, 506 
Gall-stones, 506 
Ganglion, 132 
Gas poisoning, 43 
Gastric fever, 386 
Gelsemium poisoning, 179 
Genito-urinary diseases, 655 



German measles, 366 

time required for development of, 366 

diagnosis of, 367 

symptoms of, 366 

treatment of, 367 
Gin, 294 
Girls, exercise for, 306 

physical training for, 306 
Glands, enlarged, 335 

tuberculous, 335 
Goiter, causes of, 111 

exophthalmic, 112 

symptoms of, 112 

treatment of, 112 
Gonorrhea, causes of, 655 

diagnosis of, 655 

in men, 655 

in women, 657 

prevention of, 666 

symptoms of, 655 

treatment of, 656 
Gout, 597 

acute, 599 

causes of, 597 

chronic, 600 

rheumatic, 600 

treatment of, 601 
Goutiness, treatment of, 600 
Grippe. See Influenza. 
Growing pains, 334 

Hair, 270 
Hand, broken, 71 
fractures of, 71 
sweating of, 272 
Hardening of arteries, 490 
Hay fever, symptoms of, 478 

treatment of, 478 
Headache, constant, 624 
due to: adolescence, 628 
anemia, 627 
biliousness, 626 
brain diseases, 628 
colds, 628 
constipation, 626 
decayed teeth, 626 
ear disease, 626 
eye strain, 625 
fatigue, 627 
heat stroke, 628 



740 



INDEX 



Headache, due to: indigestion, 626 
menstruation, 628 
poisoning, 626 
neuralgia, 624 
nose and throat trouble, 625 

nervous, 627 

sick. See Migraine. 
Head gear, 272 
Head injuries, 46, 51 
Heart, enlargement of, 483 

palpitation of, 486 
Heart disease, 483 

causes of, 484 

symptoms of, 485 

treatment of, 485 
Heat exhaustion, 47 
Heat prostration, 47 
Heat stroke, 47 

Heights and weights, table of, 582 
Hemorrhage. See Bleeding. 

from womb, 203 
Hemorrhoids. See Piles. 
Hereditary diseases, 316 
Heredity, 309 
Hernia, causes of, 115 

femoral, 114 

inguinal, 114 

strangulated, 115, 541 

treatment of, 116 

umbilical, 114 

ventral, 114 
Herpes, causes of, 636 

treatment of, 636 
Hiccough, 632 

causes of, 632 

treatment of, 632 
Hiccup. See Hieeough. 
Hip, broken, 72 

disease of, 347 

dislocation of, 89 

fracture of, 72 

sprain of, 26 
Hives, causes of, 148 

symptoms of, 148 

treatment of, 149 
Hoarseness, 453 
Holding the breath, 340 
Holly berries, 179 
Hookworm disease, 191 
Hornet stings, 168 



; < Horrors," 645 

Housemaid's knee. See Bunion. 
Humpback, 343 
Hydrophobia, 142 

symptoms of, 142 

treatment of, 143 
Hydroeyamus, 179 
Hydrocyanic acid, 173 
Hygiene, of digestion. 274 

personal, 265 

sexual, 676 
Hypodermic syringe, 322 
Hysteria, causes of, 619 

diagnosis of, 621 

forms of, 619 

symptoms of, 619 

treatment of, 621 

See also Unconsciousness. 

Ice, in relation to disease, 289 
Ice cream poisoning, 183 
Incontinence of urine, 673 
Indigestion. See Diseases of stomach. 

functional, 517, 525, "." 

intestinal. 565 

nervous, 512 

organic, 510, 514 
Infants. See Children. 

bathing of, 233 

care of, 226 

clothing of, 220 

feeding of, 239, 261-3 
Infection, in erysipelas. 165 

in malaris. I I 

in typhoid ieva \ W 

in yellow fever, 415 
Infectious diseases, 355 

eruptive, 356 
Inflammation, of bowels, 543 
Inflammatory rheumatism. 
Influenza, causes of. i ' 

symptoms of, 479 

treatment of. 481 
Ingrowing toe nail, eauses of, 1-S 

treatment of. 128 
Injections, hypoderi,.: : _ _ 
Injured, carrying the. 1 . _ 
Insensibility. 46 
Insomnia, 68S 
see : I S .. 



INDEX 



741 



Insomnia, treatment of, 623 
Intermittent fever, 404 
Intestinal indigestion of infants, 565 
Intoxication, 50 

See also Unconsciousness. 
Intussusception, of bowels, 541 
Iodin, 179 
Iodoform, 179 
Itch, 159 
Itching, cause of, 145 

treatment of, 146 
Ivy poisoning, symptoms of, 155 

treatment of, 156 

Jaundice, causes of, 500 

diagnosis of, 502 

symptoms of, 501 

treatment of, 502 
Jaw, dislocation of, 84 

broken, 63 

fracture of, 63 
Jigger, 172 
Joint, disease of, 603, 608 

injury to, 22 
Junket, 259 

Kerosene, extermination of mosquitoes 

by, 411 
Kidneys, inflammation of, 650 

Bright 's disease, 650 

stone in the, 536 

unconsciousness and, 53 
Knee, housemaid's, 125 

knock, 349 

sprain of, 26 
Kneepan fracture, 76 
Knock knees, 349 

Laryngitis, acute, 453 
Larynx, spasm of the, 340 
Lateral curvature of spine, 345 
Lead, 179 

Leeches, use of, 708 
Leg, bow, 348 

broken, 77 

growing pains in, 332 
Leg bones, fracture of, 77 

compound, 80 
Leukoplakia, 297, 432 
Leukorrhea, 206 



Leukorrhea, causes of, 207 

treatment of, 208 
Lice, body, 170 

clothes, 170 

crab, 170 

head, 169 
Lightning stroke, 39 
Lime, 176 

Lime poisoning, 176 
Lip, cancer of, 109 
Liver spots, 154 
Lobelia, 179 
Lockjaw, 20 
Long life, rules for, 490 
Lues, 666 
Lumbago, 606 
Lungs, bleeding from, 7 

diseases of, 458-462 

inflammation of, 462 

tuberculosis of, 465 
Lye, 176 
Lysol, 180 

Madeira, 294 
Malaria, chronic, 408 

diagnosis of, 410 

distribution of, 406 

irregular, 408 

mode of development, 404 

mosquito as cause of, 404 

pernicious, 409 

prevention of, 411 

remittent, 408 

severe, 408 

symptoms of, 407 

treatment of, 412 

typhomalarial, 408 
Marasmus, 331 
Marriage relations, 682 
Marsh fever, 403 
Mastoid inflammation, causes of, 712 

symptoms of, 712 
Masturbation, 676 

treatment of, 712 
Measles, 362 

complications in, 363 

diagnosis of, 364 

German, 366 

symptoms of, 362 

time of development required for, 362 



742 



INDEX 



Measles, treatment of, 364 
Meat as food. 282-284 

composition of, 282 
Meat broths, 572 
Meat poisoning, 182 
Medicine chest, contents of, 721 
Medicines, doses of, 723 
Membranous croup, 452 
Meningitis, carriers of, 399 

epidemic cerebrospinal, 398 

development, time required, 399 

mode of infection, 398 

symptoms of, 399 
Menopause, symptoms of, 212) 

treatment of, 214 
Menstruation, absence of, 200 

arrest of, 202 

care of, 198 

cessation of, in pregnancy, 209 

delayed, 203 

excessive, 203 

normal, 195-196 

painful, 199 

relation of, to conception, 196 

scanty, 203 • 

symptoms of, 196 
Migraine, causes of, 629 

diagnosis of, 630 

symptoms of, 629 

treatment of, 630 
Miliaria, 
Milk, as food, 285 

certified, 242 

comparative food and human value, 
240 

comparative value of cow's and 
human, 240 

composition of, 240 

condensed, 260 

dangers of cow 's milk, 183, 239, 569 

diarrhea from, 567-569 

diphtheria from, 447 

pasteurized, 242-243 

peptonized, 247 

porridge, 259 

preparation of for babies, 249 

scarlet fever from, 356-358 

typhoid fever from, 387 

tonsillitis from, 441 

tuberculosis from,. 470 



Milk, utensils for preparing, care 

of, 249 
Milk curd, 259 
Milk poisoning, 569 
Miscarriage, causes of, 211 

dangers of, 212 
Morning diarrhea 540 
Morphin poisoning, 180 
Mosquitoes, destruction of, 411 

extermination of, 411 

malaria due to, 404 

yellow fever due to, 418 
Mosquito bites, 167 
Mouth, inflammation of, 429 

sore, 429 
Mouth breathing, causes of, 437-439 

symptoms of, 439 

treatment of, 440 
Mucous colic, 539 
Mumps, complications in, 382 

development of, 381 

symptoms of, 381 

time required for, 381 

treatment of, 382 
Muriatic acid poisoning, 176 
Muscles, development of, 302 
Muscular rheumatism, 606 
Mustard bath, children and, 462 
Mutton broth, 255, 572 
Myalgia, 606 
Myopia, 693, 696 
Myxedema, 112 

Nails, bruises of, 34 

Nasal polypi, 439 

Nasal septum, deviation of, 438 

Navel, bleeding from, in newborn, 232 

rupture at, 114 

sore, 233 
Nearsightedness, 693, 696 
Neck, enlarged glands in, 335 

rheumatism of, 607 

stiff, 607 
Nervous debility, 613 
Nervous diseases, 613 
Nervous exhaustion, 613 
Nervous indigestion, 517, 527 
Nervous prostration, 613 
Nettlerash, causes of, 148 

symptoms of, 14S 



INDEX 



743 



Nettlerash, treatment of, 149 
Neuralgia, causes of, 634 

complications in, 636 

diagnosis of, 635 

facial, 637 

of chest, 635 

of stomach, 531 

symptoms of, 635 

treatment of, 636 
Neurasthenia, causes of, 613 

diagnosis of, 616 

outlook, 615 

symptoms of, 614 

treatment of, 616 
Nitrate of silver poisoning, 180 
Nitric acid poisoning, 176 
Nose, bleeding from, 421 

broken, 64 

catarrh of, 423, 437-438 

deviated septum, 438 

diseases of, 423 

foreign bodies in, 428 

fracture of, 64 

obstruction of, 437 
Nose bleed, 421 
Nux vomica poisoning, 180 

Obesity, 582 

causes of, 584 

symptoms of, 584 

treatment of, 534 
Obstruction, of the bowels, causes of, 
541 
symptoms of, 541 
treatment of, 542 
Oozing, of blood, 2 
Opium poisoning, 57 
Orange juice, 255 
Outdoor life, for consumptives, 471 

for neurasthenics, 616 
Oyster broth, 260 
Oxalic acid poisoning, 176 

Pains, abdominal, 530 

growing, 332 
Palpitation, of heart, 

causes of, 486 

symptoms of, 486 

treatment of, 487 
Paralysis, causes of, 633 



Paralysis, facial, 633 

symptoms of, 633 
treatment of, 634 
Parasites, in food, 185 

malarial, 404 

yellow fever, 414 
Paregoric, doses of, 461 
Paris green poisoning, 177 
Pasteurized milk, 242-243 
Patent foods, for infants, 261 
Pellagra, 595 
Peptonized milk, 258 
Peritonitis, acute, 543 

causes of, 543 

chronic, 543 

diagnosis of, 544 

symptoms of, 544 

treatment of, 544 
Peritonsillitis, 444 
Pernicious malaria, 409 
Personal hygiene, 265 
Petit mal, 642 
Pharyngitis, 433 
Phenacetin, 179 
Phimosis, 328 
Phosphoric acid, 176 
Phosphorus, 181 
Phthisis, 465 
Pigeon breast, 338, 437 
Piles, examination in, 120, 122 

external, 121 

symptoms of, 121 
treatment of, 121 

internal, 122 
causes of, 123 
symptoms of, 122 
treatment of, 123 
Pimples. See Acne. 
Pin worm, 189 
Pink eye, 692 
Pneumonia, death rate in, 464 

symptoms of, 462 

treatment of, 463 
Poisoning, canned meat, 184 

canned vegetable, 184 

clams, 182 

crab, 182 

cheese, 183 

fish, 182 

food, bacterial, 181 



744 



INDEX 



Poisoning, food, 

containing parasites, 181 

infected, 181 
gas, 43 

ice cream, 183 
lobster, 182 
meat, 182 
milk, 183 
mussel, 182 
oyster, 182 
potato, 183 
sausage, 182 
treatment, 185 
Poison, and antidotes, 174 
Poison ivy, 155 
Poisons, acetanilid, 175 
acids, 176 

acetic, 176 

carbolic, 176 

hydrocyanic, 179 

muriatic, 176 

nitric, 176 

oxalic, 176 

phosphoric, 176 

sulphuric, 176 

tartaric, 176 
aconite, 176 
antipyrin, 177 
alcohol, 647 

wood, 181 
alkalis, 176 
ammonia, 176 
antimony, 177 
arsenic, 177 
atropin, 177 
belladonna, 177 
bichlorid of mercury, 178 
blue vitriol, 178 
bug poison, 178 
camphor, 177 
cannabis-indica, 177 
canned food, 184 
cantharides, 177 
carbolic acid, 176 
caustic potash, 176 
caustic soda, 176 
cheese, 183 
chloral, 177 
chloroform, 178 
cocain, 178 



Poisons, colchicum, 178 
copper salts, 178 
conium, 178 

corrosive sublimate, 178 
crab, 182 
creolin, 178 
creosote, 178 
digitalis, 179 
fish, 182 
food, 181 

symptoms of, 184 

treatment of, 185 
formalin, 179 
Fowler's solution, 177 
gelsemium, 179 
headache powders, 177 
holly berries, 179 
hydrocyanic acid, 179 
hyocyamus, 179 
ice cream, 183 
iodin, 179 
iodoform, 179 
ivy, 156 

knockout drops. See Chloral, 
lead salts, 179 
laudanum, 180 
lime, 176 

quick, 176 
lobelia, 179 
lobster, 182 
lye, 176 
lysol, 180 
matches, 180 
meat, 182 

mercury. See Corrosive sublimate, 
milk, 183, 239, 569 
morphin, 180 
mussel, 182 
nitrate of silver, 180 
nux vomica, 179 
oil of turpentine, 181 
opium, 180 
oysters, 182 
paregoric, 180 
Paris green, 177 
phenaeetin, 179 
phosphorus, 180 
potato, 183 
potash, 176 
ptomain, 181 



INDEX 



745 



Poisons, "rough on rats," 177 

sausage, 182 

Scheele's green, 177 

silver nitrate, 180 

strychnin, 180 

sulphuric acid, 176 

tartar emetic, 177 

tartaric acid, 176 

tobacco, 180 

turpentine, oil of, 181 

unknown, 174 

verdigris, 178 

veronal, 181 

washing soda, 176 

white arsenic, 177 

white precipitate, 178 

white vitriol, 181 

wood alcohol, 181 

zinc salts, 181 
Polluted water, ice from, 290 
Polypi, nasal, 439 
Port wine, 294 
Potash, 176 
Pott's disease, 343 
Poultry, as food, 282-284 
Pox, 660 
Pregnancy, clothing in, 216 

dangers in, 219 

diet during, 217 

exercise during, 215 

heartburn in, 218 

hygiene of, 215 

leukorrhea in, 217 

mental state during, 219 

neuralgia in, 218 

reckoning time of, 215 

sciatica in, 218 

sexual intercourse during, 217 

signs of, 210 

sleeplessness during, 219 

symptoms of, 210 

teeth in, 216 

treatment of ills in, 217 

varicose veins during. 218 

vomiting of, 217 
Prickly heat, symptoms of, 152 

treatment of, 153 
Prolapse of bowel, 330 
Prostate glands, enlarged, 669 
Proteids, 281 



Pruritus, 146 

Ptomain poisoning, 181 

Puberty, in menstruation, 195-196 

at different ages, 195-196 
Pulse, how to feel, 320 
Pulse rate, 320 

Punctured wound, bleeding from, 13 
Pur-ins, in food, 282 
Pyorrhea alveolaris, 279 

Quinsy, causes of, 444 
symptoms of, 445 
treatment of, 446 

Eabies, symptoms of, 142 

treatment of, 143 
Rat poison, 180 
Eecipes, for babies, 253-261 

for the sick, 253-261 
Eemittent fever, 408 
Renal colic, 536 

Respiration, how to produce artificial, 
37, 42 

rapidity of, 321 
Respirations, counting the, 321 
Retention of urine, 672 
Rheum, salt, 161 
Rheumatic fever, 603 
Rheumatic gout, 6 
Rheumatism, acute, 603 

chronic, 608 

deforming, 608 

effect of, on heart, 605 

inflammatory, 603 

muscular, 606 

of chest, 607 
Rhinitis, 423 
Rib, broken, 59 

fracture of, 59 
Rickets, 338 

treatment of, 339 
Riggs' disease, 279 
Ringworm, causes of, 153 

of body, 153 

of scalp, 153 

symptoms of, 153 

treatment of, 154 
"Rough on rats," 177 
Round worm, 187 
Rubella, 366 



746 



INDEX 



Rum, 294 
Run-around, 129 
Rupture, at navel, 114 

causes of, 115 

in groin, 114 

inguinal, 114 

symptoms of, 115 

treatment of, 116 

umbilical, 114 

Salt rheum. See Eczema. 

Sarcoma, 110 

Sausage poisoning, 182 

Scabies, 159 

Scalds, 714 

Scalp, ringworm of, 153 

Scalp wounds, 14 

Scarlatina, 356 

complications in, 358 

diagnosis of, 359 

symptoms of, 358 

time required for development, 357 

treatment of, 360 
Scarlet fever, 356 
Sciatica, causes of, 637 

symptoms of, 637 

treatment of, 638 
Scorpion sting, 173 
Scrofula, 335 
Scurvy, causes of, 592 

infantile, 595 

symptoms of, 595 
treatment of, 595 

prevention of, 594 

symptoms of, 594 
Seasickness, 498 
Seat worm, 189 
Self-abuse, 676 
Septum, deviation of, 438 
Serum, anti-venomous, 141 
Sexual organs, care of, 676 

diseases of, 655 

hygiene of, in adolescence, 677-682 
for children, 677 
for infants, 676 
marital, 682 
Sexual relations, 681-683 
Shingles, 636 
Shock, electric, 41 

in wounds, 16, 55 



Shock, surgical, 55 
Shoes, proper, 272 
Shoulder, dislocation of, 86 

sprain of, 31 
Shoulder-blade, broken, 66 

fracture of, 66 
Sick, food for the, 253 
Sinusitis, 425 
Skin, callus of the, 160 

care of, 269 

chafing of, 147 

chapping of, 147 

cracks in, 147, 160 

discolorations of, 154 

diseases of, 145, 270 

irritation of, 147 

itching of, 145 
Sleeplessness, 622 
Sling, how to make, 70 
Smallpox, 368 

complications, 372 

diagnosis of, 371 

outlook in, 372 

prevention of, 373 

symptoms of, 369 

time required for development of, 
369 

treatment of, 376 
Smoker 's tongue, 297, 432 
Smoking, effect of, 297 
Snake bite, 138 

symptoms of by colubrines, 140 
by viperines, 140 

treatment of, 141 

varieties of, 138 
Soap, use of, 269 
Sore eyes, 690 
Sore mouth, aphthous, 430 

gangrenous, 431 

simple, 429 

ulcerous, 430 
Sore throat, 433 
Soups, 255, 572 
Spasm, of larynx, 340 
Spider bite, 173 
Spinal meningitis, 398 
Spine, curvature of, 343, 345 

tuberculosis of, 343 
Spleen, enlargement of, 450 
Splints, 77 



INDEX 



747 



Sprains, bandage for, 23-30 

description of, 22 

diagnosis of, 23 

of ankle, 28 

of back, 24 

of elbow, 31 

of fingers, 30 

of hip, 26 

of knee, 26 

of shoulder, 31 

of thumb, 30 

of wrist, 31 

sacro-iliac, 24 

symptoms of, 23 

treatment of, 23 
Sprue, 430 
Squint, 70 

St. Vitus 's Dance, 341 
Stiff neck, 607 
Stings, of bees, 168 

of centipedes, 173 

of hornets, 168 

of scorpions, 173 

of wasps, 168 
Stitching, of wound, 11 
Stomach, atony of, 525 

bleeding from, 7, 495, 498, 512 

cancer of, 514 
treatment of, 514 

diseases of, 505-517 

nervous dyspepsia of, 517 

neuralgia of, 50, 531 

ulcer of, 510 
Stomach trouble and gall-bladder dis- 
ease, 506 

from appendicitis, 516 
Stomach ache, 531 
Stomatitis, aphthous, 429 

gangrenous, 431 

ulcerous, 430 
Stone, in bladder, 669 

in kidney, 536 
Stoppage, of urine, 672 
Strabismus, 70 
Stricture, of urethra, 669 
Strychnin, 180 
Stye, 687 

Subcutaneous syringe, 322 
Suffocation, from gas, 43 
Sulphuric acid, 176 



Sunstroke, 47 

Suppression, of urine, 672 

Surgical dressings, 92 

Surgical outfit, first aid, 727 

Surgical shock, 55 

Swallowing foreign bodies, 133, 428 

Syphilis, causes of, 662 

diagnosis of, 662 

outlook in, 664 

prevention of, 666 

social danger of, 665 

symptoms of, 660 

treatment of, 663 
Syringe, hypodermic, 322 

Tan, treatment for, 154 

Tapeworm, 185 

Tarantula bite, 173 

Tartar emetic, 177 

Tartaric acid, 176 

Tea, use of, 290 

Teeth, care of, 278 

Teething, 237 

Temperature, how to take, 319 

Testicles, bruises of, 34 

Tetanus, 20 

Tetter, 161 

Thermometer, clinical, use of, 319 

Thighbone, broken, 74 

fracture of, 74 
Thread worm, 189 
Throat, diseases of, 421 

foreign bodies in, 428 

sore, 433-453 
Thrush, 430 
Thumb, dislocation of, 90 

fracture of, 72 

sprain of, 30 

sucking, 239 
Tic douloureux, 637 
Tobacco, 295 
Tobacco poisoning, 180 
Toe, broken, 180 
Toe nail, care of, 271 

ingrowing, 128 
Tongue, smoker's, 322 
Tonsillitis, acute, 441 

causes of, 441 

chronic, 440 

diagnosis of, 442 



748 



INDEX 



Tonsillitis, from milk, 441 

symptoms of, 442 

treatment of, 443 
Tonsils, enlarged, 440 
Tooth, ulcerated, 434 
Toothache, 437 
Training, physical, 302 
Trichiniasis, 190 
Truss, use of, 116 
Tuberculin, 470 
Tuberculosis, from milk, 466 

in children, 470 

of bones, 343 

of glands, 335 

of lungs, 465 

of spine, 343 

X-ray examination in, 470 
Tumors, 104 

benign, 104, 110 

malignant, 105 
Turbinates, enlarged, 437 
Turpentine, 181 
Typhoid fever, 386 

causes of, 387 

complications of, 392 

diagnosis of, 392 

from milk, 387 

mode of communication, 387 

prevention of, 393 

symptoms of, 389 

time required for development of, 389 

treatment of, 395 

Ulcer, of duodenum, 510 
of stomach, causes of, 512 

diagnosis of, 512 

symptoms of, 511 

treatment of, 513 
Ulcerated tooth, 434 
Unconsciousness, 45 
causes of, 45 
due to: apoplexy, 46, 52 

concussion, 51 

drunkenness, 46, 50 

diabetes, 55 

epilepsy, 46, 49 

head injuries, 46, 51 

hysteria, 46, 54 

kidney disease, 46, 53 

opium poisoning, 57 



Unconsciousness due to : 
sunstroke, 47 
surgical shock, 55 
general treatment of, 45 
Underclothing, proper, 271 
Uric acid, derivation of, 673 
Urine, incontinence of, 673 
involuntary passage of, 673 
painful passage of, 328 
retention of, 328, 672 
stoppage of, 672 
suppression of, 672 
Urticaria, 148 
Uterus. See Womb. 

Vaccination, 373 
Varicella, 377 
Varicocele, 119 
Varicose veins, 117 
Varioloid, 371 
Veal broth, 255 
Vegetables, as food, 288 
Vein, bleeding from, 4 
Veins, varicose, 117 
Verdigris, 178 
Veronal, 181 
Vision, defects of, 693 
Vitamines, 589 
Vomiting, causes of, 495 

of blood, 495, 498, 512 

of indigestion, 495 

of pregnancy, 217 

treatment of, 497 

Wakefulness, 622 
Warts, causes of, 156 

flat, 157 

moist, 157 

seed, 156 
' threadlike, 156 

treatment of, 157 
Washing soda, 176 
Wasp stings, 168 
Wasting, 331 
Water, barley, 253, 572 

egg, 256 

rules for drinking, 289 
Wax, in ear, 702 
Weak feet, 350 
Wear and tear, 490 



INDEX 



749 



Weaning, 261 

Weeping sinew, 132 

Weight and height, table of average, 

582 
Wen, 110 
Whisky, 294 
White arsenic, 177 
White vitriol, 181 
Whites, causes of, 207 

treatment of, 208 
Whitlow, 129 
Whooping cough, complications of, 385 

symptoms of, 384 

time required for development of, 383 

treatment of, 385 
Wines, 294 
Womb, cancer of, 108 

dead child in, 212 

diseases of, 198 

hemorrhage from, 203 
treatment of, 205 
Wood alcohol poisoning, 181 
Wood tick, bite of, 168 
Worms, hook, 192 

pin, 189 

round, 187 

seat, 189 

tape, 186 

thread, 189 
Wounds, adhesive plaster for, 12 

after-treatment of, 18 

about the eyes, 688 

arrest of bleeding in, 2 
from artery, 3 



Wounds, arrest of bleeding in, from 
vein, 4 

bandages for, 93 

blank cartridge, 15, 21 

bullet, 14 

caused by pistols, 15 

caused by firecrackers, 21 

cleansing of, 10 

closing of, with adhesive plaster, 11 

contused, 13 

dressing of, 10 

foreign bodies in, 9, 21 

immediate care of, 8 

incised, 13 

iodin for, 9 

lacerated, 13 

punctured, 13, 21 

revolver, 15 

rifle, 16 

scalp, 14 

shock in, 16 

stitching of, 11 

treatment of, 2, 10, 12, 17 
Wrist, broken, 70 

Colles* fracture of, 70 

sprain of, 31 

Yellow fever, 414 
diagnosis, 417 
mosquito as cause of, 415 
prevention of, 418 
symptoms of, 416 

time required for development of, 415 
treatment of, 418 



(i) 



LIBRARY OF CONGRESS % 



022 169 847 2 



